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AL ISSUE:

>SIONAL LIABILITY
)UTH CAROLINA

^lth sciences library

IVERSITY OF MARYLAND
BALTIMORE

256-7960

Proudly announces the
opening of its
message center
for physicians only.

3818 River Drive • Columbia, South Carolina 29203

CHARTER

RIVERS

HOSPITAL

2900 Sunset Blvd.
West Columbia, SC 29171
803/796-9911

1-800-922-1332

(in SC)

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION
(ISSN 0038-3139)

VOLUME 85

JANUARY 1989

NUMBER 1

EDITOR

Charles S. Bryan, M.D.

SCMA, P. 0. Box 11188
Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia

Thomas M. LeLand, M.D., Charleston

W. Curtis Worthington, Jr., M.D., Charleston

Arthur F. DiSalvo, M.D., Columbia

Frederick L. Greene, M.D., Columbia

Albert Cannon, M.D., Charleston

J, Sidney Fulmer, M.D., Spartanburg

Hunter R. Stokes, M.D., Florence

E. Conyers O'Bryan, M.D., Florence

Robert Mallin, M.D., Columbia

William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Thomas C. Rowland, Jr., M.D., President
Daniel W. Brake, M.D., President-Elect
Carol S. Nichols, M.D., Secretary
Bartolo M. Barone, M.D., Treasurer
0. Marion Burton, M.D., Speaker of the House
Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House
Charles R. Duncan, Jr., M.D., Past President

TRUSTEES

John C. Hawk, III, M.D., First District, Chairman
John B. Johnston, M.D., First District
Edward W. Catalano, M.D., Second District
Frank W. Young, M.D., Second District
Richard M. Carter, M.D., Third District
James B. Page, M.D., Fourth District
William J. Goudelock, M.D., Fourth District
Terry L. Dodge, M.D., Fifth District
James M. Lindsey, Jr., M.D., Sixth District
Stephen A. Imbeau, M.D., Sixth District
S. Perry Davis, M.D., Seventh District
John W. Rheney, Jr., M.D., Eighth District
John W. Simmons, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate
Donald G. Kilgore, Jr., M.D., Delegate
Randolph D. Smoak, Jr., M.D., Delegate
Charles R. Duncan, Jr., M.D., Alternate
J. Gavin Appleby, M.D., Alternate
Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

SPECIAL ISSUE:

PROFESSIONAL LIABILITY IN SOUTH CAROLINA

Introduction — Euta M. Colvin, M.D 5

Glancing Back — William F. Fairey, M.D 6

South Carolina Medical Malpractice Joint Underwriting

Association — Bartolo M. Barone, M.D 7

South Carolina Medical Malpractice Patients’ Compensation

Fund — Donald G. Kilgore, Jr., C. Tucker Weston, M.D 10

JUA Claims Functions — Boyce M. Lawton, Jr., M.D 11

The South Carolina Medical Association/Joint Underwriting
Association Risk Management Program — Euta M. Colvin,

M.D 16

The SCHA Loss Control Program: Reduction in Liability Exposures

for Hospitals and Physicians — Cheryl Koob, Jane Bryant 25

The South Carolina Dental Association and the S. C. Medical

Malpractice JUA — James H. Gaines, D.M.D 33

Malpractice Prophylaxis — John R. Hunt, M.D 36

So You are the Defendant in a Malpractice Action — Donald V.

Richardson, Esquire 39

The Deposition — The Doctor, The Lawyer — William F. Fairey,

M.D., LL.B 43

SPECIAL ARTICLE

A Report of the AMA Interim Meeting — John C. Hawk, Jr., M.D. . 19

EDITORIALS

Quality Assurance, Quality Management, Risk Management and
Other Buzz Words of the Eighties — How do we Use Them? —

R. L. Skinner, Jr., M.D 46

Risk Management — Euta M. Colvin, M.D 47

FEATURES

ASSOCIATION

Gray Matter 49

Information for Authors 52

SCMA Newsletter 29

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139)
— Published monthly by the South Carolina Medical Association Business office: 3210
Lernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol
Station, Columbia, SC 29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00)
included with payment of annual dues. Second class postage paid at Columbia, S. C.
POSTMASTER: Send address changes to The Journal of the South Carolina Medical
Association, P. O. Box 11188, Columbia, South Carolina 29211.

Auxiliary Page
Letter to the Editor

On the Cover

President’s Page . . .

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of
the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence
should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office
Box 1 1 1 88, Columbia, S. C. 2921 1 .

All manuscripts should be accompanied by a transmittal letter with the following paragraph: "This original
work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or
otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is
published by the SCMA."

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more
than ten references. These should be cited in the text in superscript, e.g., “Bottsford, et al.3", and should conform
to the following style: "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with
abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1983." Ordinarily, publication of four small illustrations or
tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will
be made available by the publisher.

The Journal of the South Carolina Medical Association

We have all heard for all of our lives that South Carolina ranks lowest in this or that state ranking. Well!
We now rank lowest in malpractice premiums — at least in OB-GYN — of ail the states, and that is great!
The national average malpractice premium for OB-GYNs in the United States is $37,000 per year, or an
average of $206 per delivery. In South Carolina the JUA plus PCF premium in 1988 was about $9,000 or
$54 per delivery — the lowest premium in the country. Our neighboring southern states are not nearly so
fortunate. Georgia’s premium for OB-GYNs is about $50,000 per year; in North Carolina the premium is
about $30,000; and even in Mississippi the premium is more than twice that in South Carolina. The rates
for other specialties are relatively the same.

The malpractice climate in South Carolina is much better than in most other parts of the United States.
Our JUA has been much more successful than most similar organizations in the country. After a recent
actuarial review the JUA board recommends no increase in our JUA premiums this year.

Why have we had such a favorable experience with our JUA in South Carolina? The obvious answer I
would like to give you is that we have the best doctors, the best defense attorneys, and the nicest patients in
the country.

I can enumerate several reasons for the better malpractice climate in our home state. First, South
Carolina is a small and very provincial state with a total population of about three million. There are about
5000 licensed physicians in the state, only about 3000 of whom are doing private practice. Our cities are
small and for the most part our population is fairly stable. The people of South Carolina are fairly
conservative. I truly believe that our patients and our juries are basically honest and conservative. Lack of
communication between physician and patient is the basic ingredient to most malpractice lawsuits. We
know our patients and they know us — much different from large metropolitan areas. Our juries have been,
for the most part, educable and fair.

The JUA has assumed a very firm stand under the capable leadership of Cal Stewart. The JUA has a
reputation of standing firm for trial if the experts feel a claim is defensible. The trial bar has learned not to
bring nuisance suits in hopes of an easy settlement.

The S.C. Medical Association has developed a very impressive risk management program. We have
developed a panel of experts in all specialties that review claims and records and later serve as experts —
much more credibly than the “Hired Guns”! Dr. Euta Colvin has had numerous risk management CME
programs that have all played before “Standing Room Only” crowds.

We have developed a small cadre of expert defense attorneys who have a tremendous record of
courthouse victories. We also have a group of self-trained expert witnesses in South Carolina who continue
to out-perform “experts” from out of town.

Tort reform I mention last because it has had little to do with the present situation. However, when one
considers the charitable immunity law, the amendment to the tort claims act, in addition to the tort reform
bill, we have had significant reform. We may never get caps on non-economic damages and if we did, they
would probably prove unconstitutional in our judiciary system.

South Carolina physicians are in the most enviable position in the U.S. as far as malpractice is concerned.
Communication, accessibility and quality care are most important traits of a good physician. Good
physicians, not necessarily good doctors, will have the fewest malpractice litigations.

J)t ^a1

Thomas C. Rowland, Jr., M.D.

President

January 1989

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION
(ISSN 0038-3139)

VOLUME 85

FEBRUARY 1989

NUMBER 2

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188
Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D , Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia

Thomas M. LeLand, M.D., Charleston

W. Curtis Worthington, Jr., M.D., Charleston

Arthur F. DiSalvo, M.D., Columbia

Frederick L. Greene, M.D., Columbia

Albert Cannon, M.D., Charleston

J. Sidney Fulmer, M.D., Spartanburg

Hunter R. Stokes, M.D., Florence

E. Conyers O'Bryan, M.D., Florence

Robert Mallin, M.D., Columbia

William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Vice Speaker, of the House
Charles R. Duncan, Jr., M.D., Past President

TRUSTEES

DELEGATES TO THE AMA

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

ORIGINAL SCIENTIFIC ARTICLES

Gamete Intrafallopian Transfer (GIFT): The South Carolina

Experience — Gary Holtz, M.D., Grant W. Patton, Jr.,

M.D 59

Update on Hospitalized Pesticide Poisonings in South

Carolina, 1983-1987 — Stanley H. Schuman, M.D., Dr.

P.H., Norris H. Whitlock, M.S., Samuel T. Caldwell,

M.A., Paul M. Horton, Ph.D 62

Chronic Hepatitis and Indolent Cirrhosis Due to

Methyldopa: the Bottom of the Iceberg? — William M.

Lee, M.D., William T. Denton, M.D 75

SPECIAL ARTICLE

Health Promotion Beliefs and Attitudes of Physicians:

A Survey of Two Communities in South Carolina —
Frances C. Wheeler, Ph.D., Daniel T. Lackland,

M.S.P.H., John V. Rullan, M.D., M.P.H 80

EDITORIALS

Beliefs, Attitudes and Health Promotion — Charles S. Bryan,

M.D 84

Slow Poisons? — Charles S. Bryan, M.D 86

FEATURES

Auxiliary Page 91

On the Cover 89

President’s Page 57

ASSOCIATION

Gray Matter 87

Physician Recognition Award 79

SCMA Newsletter 71

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139)
— Published monthly by the South Carolina Medical Association Business office: 3210
Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol
Station, Columbia, SC 29211.

Subscription price to non-members S25.00. SCMA members’ subscription cost ($15.00)
included with payment of annual dues. Second class postage paid at Columbia, S. C.
POSTMASTER: Send address changes to The Journal of the South Carolina Medical
Association , P. O. Box 11188, Columbia, South Carolina 29211.

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of
the South Carolina Medical Association.

INFORMATION FOR AUTHORS

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more
than ten references. These should be cited in the text in superscript, eg, "Bottsford, et al.3", and should conform
to the following style: "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with
abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1 983. ' ' Ordinarily, publication of four small illustrations or
tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will
be made available by the publisher.

The Journal of the South Carolina Medical Association

A SALUTE TO THE SOUTH CAROLINA BOARD OF MEDICAL EXAMINERS

In May 1988, House Bill #4101 was passed by an overwhelming majority with a definite threat to
override a gubernatorial veto. This Bill was amended to reduce the FLEX examination score required for
physician licensure to 74 for any day and an overall average of 75. The efforts of our state house staff
resulted in changing the original amendment from a score of 70 for any part of the exam. All of this was
done for the purpose of licensing a single physician to practice medicine in S.C.

The physician in question is probably very well qualified as he had specialty and subspecialty training
and came highly recommended. He had been strongly recruited by the hospital and the community in
which he practices. The county medical association in that community sought SCMA help in getting him
licensed.

Many members of the legislature, many of our colleagues and even some ranking political officials of
our state have asked me what SCMA was going to do about the Board of Medical Examiners and their
unbending stature which required legislation to license needed physicians. Of course my first answer is to
remind them that the Supreme Court of South Carolina in 1985 asked the SCMA to butt out of the Board of
Medical Examiners’ business.

Recently three SCMA officers met with three officers of the S.C. State Board of Medical Examiners for
an open discussion of our differences of opinion. Since your president and the president of the Board have
been close friends for some 35 years, you can be assured that the discussion was very frank and open.

The following data has been reviewed from the last three years’ work of the Board. Of the 1,529
physicians licensed, 82% were based on national board exams or old State Board exams. Only 18% were
based on FLEX scores. Of these, only 14% were U.S. graduates. The total number of applicants for
licensure in S.C. who were rejected for not meeting minimum standards of the Board were 44 or 2.8% in
this three-year period. SPEX, a new exam for physicians entering S.C., is designed for the practicing
physician who has been out of school for some time. Reportedly it is passed without special preparation by
most physicians in active practice. A recent graduate of any good medical school should score in the mid to
high 80s on the FLEX exam.

South Carolina is a very attractive place to settle. It is certainly a very attractive place to practice
medicine. The malpractice climate is much more favorable than that in even our neighboring states. We
are developing rapidly in industrial and economic stature. Our mountains, coast and climate are attracting
a great number of retirees. We want and can have capable, well-trained and properly motivated
physicians in South Carolina. Let’s not lower our standards even to get lesser qualified doctors in poorly
served rural areas. Our citizens are better served by good transportation.

I understand that there are several other less than qualified young physicians who were educated in off-
shore medical schools standing in the wings waiting for their chance at “Legislative Licensure” this next
session. Qualifications for licensure to practice medicine are best not legislated by well-meaning politi-
cians— regardless of the stature of the candidate’s parents or friends!!

We should salute our Board of Medical Examiners for keeping the standards and quality of our
practicing physicians at a high level. This best serves the citizens of our great state.

Sincerely,

Thomas C. Rowland, Jr., M.D.

President

February 1989

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION
(ISSN 0038-3139)

VOLUME 85 MARCH 1989 NUMBER 3

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188
Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia

Thomas M. LeLand, M.D., Charleston

W. Curtis Worthington, Jr., M.D., Charleston

Arthur F. DiSalvo, M.D., Columbia

Frederick L. Greene, M.D., Columbia

Albert Cannon, M.D., Charleston

J. Sidney Fulmer, M.D., Spartanburg

Hunter R. Stokes, M.D., Florence

E. Conyers O'Bryan, M.D., Florence

Robert Mallin, M.D., Columbia

William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Vice Speaker of the House
Charles R. Duncan, Jr., M.D., Past President

TRUSTEES

DELEGATES TO THE AMA

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

ORIGINAL SCIENTIFIC ARTICLES

Clinical Experience with Ciprofloxacin: Analysis of a Multi-
Practice Study — C. P. Dunbar, M.D., Ronald L.
Ashton, M.D., Larry Atkinson, M.D., Henry F.
Crotwell, M.D., Henry M. Faris, M.D., Howard G.
Royal, Jr., M.D., Duncan W. Tyson, M.D., Charles H.

White, Jr., M.D 97

Seroprevalence of Human Immunodeficiency Virus in
Mental Health Patients — Walter K. Clair, M.D.,

G. Paul Eleazer, M.D., Linda Jean Hazlett, B.A.,

B. Ann Morales, B.A., Judith M. Sercy, B.S., Lee V.

Woodbury, M.D 103

Lymphomatoid Papulosis: Mostly Benign but Potentially
Malignant — A Case Report with a Fatal Outcome —

Larry H. Parrott, M.D 113

Project Readiness II: Some Results from a Physicial Fitness
and Health Enhancement Program for Law
Enforcement Personnel — Stanley J. LeProtti, M.Ed.,

Warren K. Giese, Ph.D., John H. Spurgeon, Ph.D.,

James A. Keith, Ph.D., Stanley S. Juk, Jr., M.D.,

Clarence G. Robinson, M.D., Sandor Molnar, Ph.D.,

J. David Branch, M.S 119

EDITORIAL

Ciprofloxacin: Panacea or Blunder Drug? — Charles S.

Bryan, M.D 131

FEATURES

Auxiliary Page 138

On the Cover 133

President’s Page 95

ASSOCIATION

CME Calendar 127

Gray Matter 135

SCMA Newsletter 109

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of
the South Carolina Medical Association.

INFORMATION FOR AUTHORS

All manuscripts should be accompanied by a transmittal letter with the following paragraph: “This original
work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or
otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is
published by the SCMA."

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more
than ten references. These should be cited in the text in superscript, e.g., “Bottsford, et al.3", and should conform
to the following style "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with
abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1 983. ' ’ Ordinarily, publication of four small illustrations or
tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will
be made available by the publisher.

The Journal of the South Carolina Medical Association

A SALUTE TO MIKE AND ANDY

Having been reared in the modest home of a public school teacher and having worked hard to obtain my
medical education, and having worked hard to accumulate whatever worldly goods I have acquired, I can
assure you that I have very little time for freeloaders, bureaucratic intrusion, and socialism in our medical
system. However, there are two persons in South Carolina who are involved in the bureaucracy who have
become my good friends and good friends of medicine in South Carolina during my term as your
president. I would like to take this opportunity to recognize and thank them both.

Mike Jarrett, Commissioner of DHEC, is doing an outstanding job for the well-being of our citizens. He
is very involved in improving the perinatal health in S. C. (which may be the worst in the world). He is
dealing with toxic and other waste disposal problems in an orderly manner, and he constantly seeks
consultation of your president and other officers and staff of the SCMA before making decisions which
affect our practices. Mike is always available to SCMA for advice or help with any mutual problem.

Dr. Andy Laurent is the Executive Director of the State Health and Human Services Finance
Commission — put simply, he is in charge of Medicaid reimbursement in South Carolina. Early after his
appointment, Andy met with SCMA leadership in an effort to determine why so many physicians refused
to care for Medicaid patients. Of course he knew that fees were low, but we must be reminded that these
are poor people — patients who traditionally have had free care — or at least they usually did not pay
anything for it. Fees have been increased. Medicaid reimbursement in South Carolina exceeds Medicare
payments in some cases. Andy also heard our complaints of returned claims, stymied cash flow, negative
attitudes, poor access of patients to the system and the “program integrity’’ or audit system problems. He
has solicited all our complaints both individually and collectively.

Not only has he heard our problems, but he is doing something about them. Andy has personally worked
through the claims process and has identified the most common causes for rejection. He is educating his
people to positive attitudes and is trying to improve and simplify access for patients. He has discovered a
lot of errors on our part and will educate us, if we ask for help.

Mike and Andy are combining forces to find innovative ways to get more funds and patients into the
system. They are both sincerely interested in good health and good health care for these less fortunate
South Carolinians. They both are motivated to help us provide this care with the least hassle and with
reasonable reimbursement.

We physicians must remember that those of us who received our medical education in South Carolina
did so at a cost of some $50,000 to $60,000 a year to our state. We owe something back for this help. Part of
our debt is to provide care for our less fortunate. It disturbs me, Andy, Mike, the Governor and our
Legislators to hear of a physician, especially a young physician, publicly refusing to accept Medicaid
patients.

I salute my new friends Mike and Andy and thank them on behalf of our association for the services they
are providing which many times seem thankless, I am sure. I implore you all to share the load, and it will
not be too heavy for any of us. We must voluntarily help care for these less fortunate people or their care
will surely be mandated.

Sincerely,

Thomas C. Rowland, Jr., M.D., President

March 1989

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION
(ISSN 0038-3139)

VOLUME 85 APRIL 1989 NUMBER 4

EDITOR

Charles S. Bryan, M.D.

SCMA, P. 0. Box 11188
Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia

Thomas M. LeLand, M.D., Charleston

W. Curtis Worthington, Jr., M.D., Charleston

Arthur F. DiSalvo, M.D., Columbia

Frederick L. Greene, M.D., Columbia

Albert Cannon, M.D., Charleston

J. Sidney Fulmer, M.D., Spartanburg

Hunter R. Stokes, M.D., Florence

E. Conyers O’Bryan, M.D., Florence

Robert Mallin, M.D., Columbia

William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Vice Speaker of the House
Charles R. Duncan, Jr., M.D., Past President

TRUSTEES

DELEGATES TO THE AMA

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

ONE HUNDRED FORTY-FIRST ANNUAL MEETING

Introduction 145

Schedule of Events 146

Delegates and Alternates 161

Officer Reports 167

Trustee Reports 179

Committee Reports 186

Report of the Executive Vice President 196

SCMA Delegation to the AMA Report 198

Report of the Editor 199

SCMA Members’ Insurance Trust Report 199

SCIMER Report 200

SOCPAC Report 200

Report of the S. C. Medical Care Foundation 201

Report of the S. C. Department of Health &

Environmental Control 201

Report of the S. C. State Board of Medical Examiners 205

Resolutions 206

AMA Special Guest 206

SOCPAC Luncheon Speaker 207

Leonard W. Douglas, M.D., Memorial Lecture Speaker .... 207

Exhibitors 214

Acknowledgments 215

EDITORIALS

Newborn Screening for HIV Antibody — Arthur F. DiSalvo,

M.D., William B. Gamble, M.D 208

Peer Review Where It Counts — Charles S. Bryan, M.D 209

FEATURES

Auxiliary Page 212

On the Cover 211

President’s Page 143

ASSOCIATION

Gray Matter 203

SCMA Newsletter 175

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of
the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence
should be addressed: The Editor. JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office
Box 11188, Columbia, S. C. 29211.

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more
than ten references. These should be cited in the text in superscript, e.g., "Bottsford, et al.3", and should conform
to the following style: "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with
abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1 983. ' ' Ordinarily, publication of four small illustrations or
tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will
be made available by the publisher.

144

The Journal of the South Carolina Medical Association

THANK YOU AND FAREWELL

It is hard to believe that my year as President of the SCMA will be over this month. It seems like such a
short time and so little has been accomplished. On the other hand, I am not sure how much more one could
stand!

I have certainly enjoyed the privilege of being your President for the past year. I have enjoyed
representing you in national forums, our legislature, and the state agencies. I have enjoyed the hospitality
of many county societies and regret that time did not allow a visit to all of them. My relationship with the
media has been pleasant and I hope positive for our association and the profession. The turf battles and the
changing PRO have been challenges in which we have prevailed. My rapport with our auxiliary has been
good, and I am proud to see “The Van” on the road. I have especially enjoyed this page — a true luxury to
be able to express one’s thoughts to an open forum. I have even enjoyed the chicken dinners!

I would like to take this last page to thank all the people who have made my year so pleasant. Dan Brake,
President-Elect, and Chris Hawk, Chairman of the SCMA Board, have been very supportive throughout
the year. They will provide excellent leadership for the SCMA in the future. The members of the Board of
Trustees of the SCMA have all been very supportive. They have offered good advice and have made wise
decisions for the good of all. The members of the AM A Delegation have always offered wise counsel and
support in more ways than I can enumerate. To all of the SCMA leadership, I say thank you!

Bill Mahon has been chauffeur, advisor and friend. He has provided support far beyond the require-
ments of his job description. The other members of the SCMA staff are fantastic. The cohesiveness and
cooperation of all our staff members are outstanding. I can honestly say that I have not heard of an
unpleasant situation at SCMA Headquarters this entire year. Thanks to all of you for a job well done, and
for making my job so easy.

I must take this opportunity to publicly thank Isabelle, my wife and good friend, for tolerating my
schedule and supporting my projects. I must also thank my partners, Nat Salley, Dave Postles, and Jimmy
Stands for all their support and toleration of my many absences from my office. Special thanks to Lisa
Bishop, my secretary, for keeping me “on track” during the year. I must not forget to thank my patients
who have remained loyal in spite of missed and changed appointments.

Last and most important, I would like to thank you — the membership. You have my sincere apprecia-
tion for the confidence and support you have given me that has made my year of service successful. Thank
you for the privilege of becoming “one of a hundred. ” SCMA can only have 100 presidents per century and
I am very proud to have been elected to this group. As I complete my year as your president, I will join
other members of my class for our 30th MUSC class reunion. What a way to end the year!

Thank you for the greatest honor of my life — to have served as your President!

Sincerely.

Thomas C. Rowland, Jr., M.D.
President

April 1989

143

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

(ISSN 0038-3139)

VOLUME 85 MAY 1989 NUMBER 5

EDITOR

Charles S. Bryan, M.D.

SCMA, P. 0. Box 11188
Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia

Thomas M. LeLand, M.D., Charleston

W. Curtis Worthington, Jr., M.D., Charleston

Arthur F. DiSalvo, M.D., Columbia

Frederick L. Greene, M.D., Columbia

Albert Cannon, M.D., Charleston

J. Sidney Fulmer, M.D., Spartanburg

Hunter R. Stokes, M.D., Florence

E. Conyers O’Bryan, M.D., Florence

Robert Mallin, M.D., Columbia

William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Vice Speaker of the House
Charles R. Duncan, Jr., M.D., Past President

TRUSTEES

DELEGATES TO THE AMA

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

ORIGINAL SCIENTIFIC ARTICLES

The Non-Operative Care of the Vascular Surgical Patient —

Gilbert B. Bradham, M.D 221

Utility of Lesser Saphenous Vein as a Substitute Conduit —
Arthur Grimball, M.D., B. Randolph Bradham, M.D.,

F. Reid Locklair, M.D 226

Takayasu’s Arteritis — John T. Tolhurst, M.D., Grady H.

Hendrix, M.D 234

SPECIAL ARTICLE

Physician Manpower and Graduate Medical Education: A
Review with Implications for State Policy
Development — Julie Johnson McGowan, G. Dean
Cleghorn, Ed.D 239

EDITORIALS

Policy Development for Medical Education in South

Carolina — G. William Bates, M.D 247

Working Together Makes Sense and Progress — J. O’Neal

Humphries, M.D 248

FEATURES

Auxiliary Pages 257

On The Cover 250

President’s Pages 253

ASSOCIATION

Gray Matter 251

Physician Recognition Award 249

SCMA Newsletter 229

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of
the South Carolina Medical Association.

INFORMATION FOR AUTHORS

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more
than ten references. These should be cited in the text in superscript, e.g., "Bottsford, et al.3”, and should conform
to the following style: “3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with
abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1 983. ' ' Ordinarily, publication of four small illustrations or
tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will
be made available by the publisher.

220

The Journal of the South Carolina Medical Association

Now America’s
oldest professional

liability insurer
has come to
South Carolina.

The newest professional liability
insurer in South Carolina is the
oldest in the nation. The Medical
Protective Company pioneered
the concept of professional pro-
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With the current liability crisis
escalating, you need to take a
close look at your coverage and
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serve you.

) yo:yi» yAy.'ra. fc-riit-v.vA

Stuart Mitchelson, P.O. Box 13489
Charlotte, North Carolina 28211, (704) 541-8020

VOLUME 85
JUNE 1989
NUMBER 6

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Original Scientific Articles

267 Trends in Cardiovascular Mortality and Risk
Factor Levels in South Carolina: Significance
for Prevention

Carlton A. Homung, Ph.D., Ernest P. McCutcheon, M.D.

275 Advances in the Treatment of Supraventricular
Tachycardia

Paul C. Gillette, M.D., Fred A. Cranford, M.D., Derek A.
Fyfe, M.D., Ashby B. Taylor, M.D., Henry B. Wiles, M.D.

283 Descending Thoracic Aorta to Femoral Artery
Bypass

R. Randolph Bradham, M.D., P. Reid Locklair, Jr., M.D.,
Arthur Grim ball, M.D.

292 Myasthenia Gravis Presenting as Respiratory
Failure: Confusion with a Psychiatric Illness

C. Bryan Jordan, II, M.D., Harold G. Morse, M.D., Larry

S. Atkinson, M.D.

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical
Association Business office: 3210 Femandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC
29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class
postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box
11188, Columbia, South Carolina 29211.

Editorial

296 True (Palmetto) Blue

Charles S. Bry an, M.D.

Features

301 Auxiliary Page

297 On The Cover
262 President’s Page

Association

287 CME Calendar

299 Gray Matter

294 Physician Recognition Awards
279 SCMA Newsletter

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL
ASSOCIATION, Post Office Box 11188, Columbia, S. C. 29211.

All manuscripts should be accompanied by a transmittal letter with the following paragraph: "This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby
transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA."

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, e g., "Bottsford, et
al.3", and should conform to the following style: "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. J S C Med Assoc 79: 57-62,
1983." Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will be made available by the
publisher.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188
Columbia, S. C. 29211

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia,
Editor Emeritus

Charles N. Still, M.D., Columbia
Thomas M. LeLand, M.D., Charleston
W. Curtis Worthington, Jr., M.D., Charleston
Arthur F. DiSalvo, M.D., Columbia
Frederick L. Greene, M.D., Columbia
Albert Cannon, M.D., Charleston
J. Sidney Fulmer, M.D., Spartanburg
Flunter R. Stokes, M.D., Florence
E. Conyers O'Bryan, M.D., Florence
Robert Mallin, M.D., Columbia
William H. Flunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House
Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

J. Chris Hawk, III, M.D., First District, Chairman
John B. Johnston, M.D., First District
Edward W. Catalano, M.D., Second District
Frank W. Young, M.D., Second District
Richard M. Carter, M.D., Third District
James B. Page, M.D., Fourth District

William J. Goudelock, M.D., Fourth District
Roger Gaddy, M.D., Fifth District
James M. Lindsey, Jr., M.D., Sixth District
Stephen A. Imbeau, M.D., Sixth District
J. Capers Hiott, M.D., Seventh District
Dallas W. Lovelace, III, M.D., Eighth District
Carol S. Nichols, M.D., Ninth District

DELEGATES TO THE AMA

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

264

The Journal of the South Carolina Medical Association

Your SCMA Board of Trustees and staff get frequent complaints from physicians throughout the
state who are upset about problems they are having in their practice and want us to help. We have
not denied help to physicians who are not members of the SCMA, but you would be amazed at the
number of complainers who have not paid their dues to the SCMA and the AMA. They are the
“free-riders” we have been talking about on our membership posters. These free-riders are mostly
good, caring physicians, but often in a three-man group, for example, one member of the group joins
and the other members of the group get a free ride. This is totally unfair to the paying members of
this association. As you know, last year the House of Delegates approved the first dues increase in
ten years. This increase would not be necessary if we could get all the “free-riders” to pay their fair
share. You can help! The delegates from your county have a list of those who are not members. Urge
those non-members to join and become involved!

As I stated at the House of Delegates I really am looking forward to coming to your county
medical society meetings. Having graduated from Wofford College and MUSC, I have old friends in
every county in this state that I have not seen for a long time. I look forward to renewing old
friendships. I will be wearing the SCMA medallion in honor of John Dessaussure Gilland, III. I
hope it will be an inspiration to you, as it is to me, to follow Dr. Gilland’s example of involvement
and commitment to our profession and the patients we serve.

Daniel W. Brake, M.D.
President

June 1989

263

VOLUME 85
JULY 1989
NUMBER 7

^Journal ?,

THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Original Scientific Articles Special Articles

311 Lyme and Other Tick-Borne Diseases Acquired
in South Carolina in 1988: A Survey of 1,331
Physicians

Stanley H. Schuman, M.D., Dr. P.H., Samuel T. Caldwell,
M.D.

317 Acute Pancreatitis in a Five-Year-Old Male

Timothy J. Mader, M.D., Jeter P. Taylor, M.D., Terrance
P. McHugh, M.D.

327 Marfan Syndrome in the Parturient

M. K. Bailey, M.D., R. Hwu-Yun, M.D., J. D. Baker, III,
M.D., J. E. Cooke, M.D., J. M. Conroy, M.D.

323 The Annual Meeting of the AMA: Report of the
SCMA Delegation

John C. Hawk, Jr., M.D.

331 Eradication of Filariasis in South Carolina: A
Historical Perspective

Wade D. Reynolds, M.P.H., Francisco S. Sy, M.D., Ph.D.

Features

349 Auxiliary Page
347 Letter to the Editor
344 On The Cover
307 President’s Page

Association

Editorial

341 Ticks, Terrorism and Tetracyclines

Charles S. Bryan, M.D.

345 Gray Matter
323 SCMA Newsletter

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical
Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC
29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class
postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box
11188, Columbia, South Carolina 29211.

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL
ASSOCIATION, Post Office Box 11188, Columbia, S. C. 29211.

All manuscripts should be accompanied by a transmittal letter with the following paragraph: "This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby
transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA."

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, e.g., "Bottsford, et
al.3", and should conform to the following style: "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. JSC Med Assoc 79: 57-62,
1 983. ' ' Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will be made available by the
publisher.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188
Columbia, S. C. 29211

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia,
Editor Emeritus

Charles N. Still, M.D., Columbia
Thomas M. LeLand, M.D., Charleston
W. Curtis Worthington, Jr., M.D., Charleston
Arthur F. DiSalvo, M.D., Columbia
Frederick L. Greene, M.D., Columbia
Albert Cannon, M.D., Charleston
J. Sidney Fulmer, M.D., Spartanburg
Hunter R. Stokes, M.D., Florence
E. Conyers O'Bryan, M.D., Florence
Robert Mallin, M.D., Columbia
William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House
Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

DELEGATES TO THE AMA

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

308

The Journal of the South Carolina Medical Association

At the May meeting of the SCMA Board of Trustees, we reaffirmed the previous position, originally set in
1984, which stated that the SCMA go on record as “opposing the UCR reimbursement system in its current
form because it is discriminatory against patients and physicians alike, and the SCMA supports equal
reimbursement by third party payors for equal services, with no mandatory assignment, the freedom to balance
bill and an upgrade of reimbursement schedules every six months.”

To understand this position, it might be worthwhile to review the circumstances in 1984 which led to its
adoption. First, the UCR (usual, customary and reasonable) which Medicare utilizes in South Carolina is not
usual and customary — and it certainly is not reasonable. The principle was to utilize physicians’ fees to arrive at
the 75th percentile to determine the Medicare allowable charge. However, each physician and each specialty
had different fees, so this system rewarded the physician who charged the highest rates and penalized the
physician who tried to keep his fees down. For example, if a patient went to one surgeon for a procedure, the
charge and the UCR may be the same — $300; but suppose another patient went to a different surgeon for the
identical procedure, this surgeon’s fee could be $300 and his UCR only $200. So, one patient may have an out-
of-pocket cost of $100, although both patients paid the same insurance premium.

The specialty differentiation at times would also be humorous if it weren’t so sad. For example, guess which
specialty was reimbursed the highest fee for a sigmoidoscopy. If you guessed the gastroenterologist, you guessed
wrong. Ophthalmologists were paid more than gastroenterologists for a sigmoidoscopy because only a few
ophthalmologists filed that code and their fees and resulting UCRs were higher. The only fair system, then,
would be to allow the physician to set a reasonable fee for his service and an insurance company reimburse all
patients the same fee for that service. Then the patient could pay the physician the balance, allowing all patients
to receive the same amount for the same procedure regardless of the physician who provided the service.
Sounds simple enough, doesn’t it?

In 1983, the SC Academy of Family Physicians wrote the Insurance Commissioner stating that the UCR
reimbursement system discriminated against patients and physicians alike, and that Blue Cross and Blue
Shield should eliminate the UCR with specialty prevailings and calculate one allowable charge for each code.
The carrier responded to the Insurance Commission that since this would affect all of the state’s physicians,
they could not consider such a major change without the endorsement of the SCMA. At about the same time, at
the AMA Interim Meeting, the AMA House of Delegates voted to change the AMA policy on physician
reimbursement from the UCR concept to the indemnity method. Thus, on January 13, 1984, after consider-
ation by a subcommittee and after careful deliberation, the SCMA Council voted to adopt the position stated
above. It was further adopted by the SCMA House of Delegates.

Blue Cross and Blue Shield implemented a prevailing fee schedule July 1, 1984 and eliminated the
“customary” charge schedule, further requesting that HCFA allow them to implement the same schedule for
Medicare patients. A decision was deferred because of a pending lawsuit in the state of Michigan on the same
subject. In April of this year, Senator Hugh Leatherman, working with our congressional delegation to
eliminate unreasonable Medicare payment differentials, requested Blue Cross and Blue Shield to urge HCFA to
implement a prevailing charge screen with no specialty differentiation. This, then, resulted in the SCMA’s
reaffirming its previous position in support of eliminating the UCR reimbursement system.

If, indeed, this concept is implemented by HCFA, it will have NO effect on your current charges to Medicare
patients. There will be only one fee (or Medicare allowed charge) for each CPT code for all physicians, and all
patients will be reimbursed the same fee for the same service regardless of their physician. This will serve two
purposes: ( 1 ) it will standardize the charge for a procedure so that all Medicare patients will receive the same
amount of reimbursement for that procedure; and (2) it will unite us as one and hopefully prevent any specialty
group from pulling out and trying to negotiate separate contracts with Medicare. This would be nonproductive,
divide our organization and destroy our private practice of medicine. United we stand!

Daniel W. Brake, M.D.
President

July 1989

307

VOLUME 85
AUGUST 1989
NUMBER 8

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Original Scientific Articles

357 Regionalized Perinatal Care in South Carolina

Thomas C. Hulsey, MSPH, Sc.D., Henry C. Heins, M.D., Terry A. Marshall, M.D., Mary Lou
Martin, MSN, R.N., Tom W. McGee, M.A.T., Marie C. Meglen, MS, C.N.M., Susie F. Peden, BSN,
M.H.S.A., William B. Pittard, M.D., David H. Wells, M.D.

Features Editorial

395 Auxiliary Page
393 On The Cover
353 President’s Page

389 The Essential Healer

Charles G. Sasser, M.D.

Association

387 Gray Matter
371 SCMA Newsletter

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical
Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC
29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class
postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box
11188, Columbia, South Carolina 29211.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188
Columbia, S. C. 29211

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia,
Editor Emeritus

Charles N. Still, M.D., Columbia
Thomas M. LeLand, M.D., Charleston
W. Curtis Worthington, Jr., M.D., Charleston
Arthur F. DiSalvo, M.D., Columbia
Frederick L. Greene, M.D., Columbia
Albert Cannon, M.D., Charleston
J. Sidney Fulmer, M.D., Spartanburg
Hunter R. Stokes, M.D., Florence
E. Conyers O’Bryan, M.D., Florence
Robert Mallin, M.D., Columbia
William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House
Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

DELEGATES TO THE AMA

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

354

The Journal of the South Carolina Medical Association

President's Page

LET’S GET IT TOGETHER

Not too many years ago doctors were concerned about the growing number of patients who were
inadequately insured. To try to help these people the physicians founded Blue Shield. They agreed
to accept the allowed charge as payment in full. In those days, the allowed charge was reasonable and
most physicians were “participating” physicians. The Blue Cross and Blue Shield Board of Trustees
was made up of lay people plus a number of physicians. As the years have passed, we have seen our
numbers decrease to one physician on the board. We have also seen an attitude change, as reflected
in a recent newspaper article interviewing Blue Cross and Blue Shield President, M. Edward Sellers,
and Chairman of the Board, Joe Sullivan. If this negative philosophy persists, there can be only
more problems for the patients, the doctors, the hospitals and, eventually, for Blue Cross and Blue
Shield.

When Blue Cross and Blue Shield began serving as the intermediary for Medicare they began
denying claims retroactively. They also began retroactive denials for their private insurance
company. It was interesting that other insurance companies were not utilizing the same retroactive
denial procedure as Blue Cross and Blue Shield. Before long it was difficult to tell the difference
between Blue Cross and Blue Shield and Medicare. In the 1970s the SCMA fought to stop the
retroactive denial process and tried to establish a concurrent review system. We worked with Blue
Cross and Blue Shield and tried to improve the quality of reviewers who were denying claims. Blue
Cross and Blue Shield also worked with us and we were able to find competent, practicing
physicians to do their review work.

It is interesting to note that Blue Cross and Blue Shield recently got the contract for CHAMPUS
and the SCMA is starting to get complaints about denials of CHAMPUS claims. This was not a
problem with the previous intermediary, but Blue Cross and Blue Shield might say that the former
intermediary was not denying enough claims. We also continue to get complaints about Medicare
and about Blue Cross and Blue Shield as a private company and, again, most of these complaints
deal with denied claims. Some of these denials are legitimate, but there are also claims which are
denied inappropriately. In these situations either the patient pays out of pocket for the service or the
physician provides a service for which he is not paid. Either way, Blue Cross and Blue Shield gets the
premium from the patient and doesn’t have to pay the claim. How many thousands or millions of
dollars of claims are denied each year? Only Blue Cross and Blue Shield can answer that question.

This problem needs to be addressed. One possible solution would be to set up a liaison committee
between the physicians and Blue Cross and Blue Shield for their private company as well as
Medicare and CHAMPUS. I’ve already met with representatives from Medicare and Blue Cross
and will meet with representatives from CHAMPUS to try to improve relations. For me to
effectively discuss the problems with the carrier requires that you notify us of any claims that are
denied inappropriately. This will allow SCMA to document the severity of the problem. Hopefully,
Blue Cross and Blue Shield will be receptive to our patient and physician problems and we can work
to insure true peer review and effective claims administration.

Daniel W. Brake, M.D.

President

August 1989

353

VOLUME 85
SEPTEMBER 1989
NUMBER 9

^Journal t,

THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

SYMPOSIUM: Otolaryngology and Head and Neck Surgery

GUEST EDITORS: J. David Osguthorpe , M.D., F. Johnson Putney , M.D.

441 Dizziness: Current Evaluation

Warren Y. Adkins, M.D., William J. Frarel, M.D.

444 Hearing Conservation and New Techniques
in Rehabilitation

403 Indications for Tonsillectomy and
Adenoidectomy

Richard M. Carter, M.D., J. Capers Hiott, M.D.

405 Current Techniques in Evaluation of a Neck
Mass

Robert C. Jordan, M.D., Augustus J. Goforth, in,
M.D.

409 Multimodality Treatment of Advanced Head
and Neck Carcinoma

L. S. Carlson, M.D., R. Stuart, M.D., J. D.
Osguthorpe, M.D.

415 Inhalant Allergies: Skin Versus In Vitro
Testing

Gien Hoang, M.D., Robert G. Mahon, Jr., M.D.

417 Endoscopic Technique for Sinus Surgery

Juan A. Brown, M.D., L. Ronald Hurst, M.D.

425 External Rhinoplasty

William R. Lomax, M.D., Kenneth A. Bronn,

M. D.

429 Adjunctive Procedures in Surgery of the
Aging Face

Paul T. Davis, M.D., Calhoun D. Cunningham,
M.D.

R. Stewart Bauknight, M.D., Robert C. Waters,
M.D., Robert M. Poland, M.A.

447 Management of Post-Intubation and Post-
Traumatic Airway Stenosis

Lucinda A. Halstead, M.D., James T. Bowles,
M.D.

Editorial

450 Otolaryngology— Head and Neck Surgery

F. Johnson Putney, M.D.

Features

451 Auxiliary Page
449 On The Cover
399 President’s Page

Association

437 CME Calendar
427 Gray Matter
443 Physician Recognition Award
421 SCMA Newsletter

THE JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina
Medical Association Business office: 3210 Femandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station,
Columbia, SC 29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class
postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box
11188, Columbia, South Carolina 29211.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188
Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia,
Editor Emeritus

Charles N. Still, M.D., Columbia
Thomas M. LeLand, M.D., Charleston
W. Curtis Worthington, Jr., M.D., Charleston
Arthur F. DiSalvo, M.D., Columbia
Frederick L. Greene, M.D., Columbia
Albert Cannon, M.D., Charleston
J. Sidney Fulmer, M.D., Spartanburg
Hunter R. Stokes, M.D., Florence
E. Conyers O'Bryan, M.D., Florence
Robert Mallin, M.D., Columbia
William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House
Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

DELEGATES TO THE AMA

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

400

The Journal of the South Carolina Medical Association

HEALTHCARE 2000

At our Annual Meeting I promised to form an ad hoc committee to study our healthcare system.
We had our first meeting in July and I feel confident we will bring some constructive recommenda-
tions to our House of Delegates next year. Our committee consists of representatives from
government, Medicare, Medicaid, hospitals, physicians, nurses, nursing homes. Medicare recip-
ients (AARP), private business, private insurance companies and the legal profession. After our first
meeting it is quite evident that we will have to address two major problems: ( 1 ) how to cut medical
costs without affecting quality; and (2) how to redistribute the total healthcare dollar so that
everyone is paying their fair share according to their ability to pay. These arc tough questions. Some
of the decisions that will follow to address costs will have to include a closer look at heroics (in
medicine), such as performing CPR on a patient who has been in a nursing home with a stroke,
being tube fed, with no mental responses. We also will have to look at neonatal nurseries. There are
many patients we keep alive with respirators, etc., for days to weeks at tremendous financial and
emotional expense to the families. We will have to include our medical ethics committee as well as
the legal profession in discussing these problems.

In discussing the distribution of the total healthcare dollar we will accumulate data on exactly
what percent is paid by all the recipients. For example, the healthcare dollar is paid by ( 1 ) Medicare/
Medicaid — but they frequently do not pay a full dollar for a dollar’s worth of service; (2) the
uninsured or inadequately insured — these also do not pay a full dollar for a dollar’s worth of service;
(3) private patients and private business — usually pay in full plus they pay for the deficit created by
Medicare/Medicaid and the uninsured and inadequately insured. The percent of private paying
patients continues to decrease but the percent they pay of the healthcare dollar continues to
increase. We cannot continue in this direction.

We will need to look closely at businesses Medicare has created such as nursing homes, home
healthcare services and medical supplies. We need to address how physicians can become more cost
conscious about practicing medicine without affecting the quality of care we give our patients. We
also need to address some physicians’ charges as well as look at socialized medicine as practiced in
other countries. These are a few issues we will have to address over the next year.

You may be interested in knowing that we are not the only people concerned about healthcare
costs. Senators Hugh Leatherman and Ed Salceby have formed separate committees to address this
issue and these committees have begun their work.

I can assure you of a dramatic change in the current healthcare system by the year 2000.
Hopefully, the change will be what’s best for the American people. I promise to dedicate my time
and energies to attempt to correct the flaws in our current system rather than allowing our country to
move toward socialized medicine.

Daniel W. Brake, M.D.
President

September 1989

399

VOLUME 85
OCTOBER 1989
NUMBER 10

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Original Scientific Articles

459 How Good (or Bad) is the Pap Smear?

William T. Creasman, M.D.

463 Utilization of Amniocentesis and Chorionic
Villus Sampling by South Carolina Women 35
Years of Age and Older

Cam Knutson, M.S., S. R. Young, Ph.D., Ronald V. Wade,
M.D., and Robert G. Best, Ph.D.

469 Idiopathic Arteriovenous Renal Vascular
Malformation Treated by Ex Vivo Repair

William R. Morgan, M.D., James A. Majeski, M.D., Ph.D.

Special Article

481 Knowledge, Perceived Risk, and Beliefs about
AIDS among High School and College Students
in South Carolina

Francisco S. Sy, M.D., Dr.P.H., Yvonne Freeze-McFJwee,
M.S.P.H., Carol Z. Garrison, Ph.D., and Kirby L. Jackson,
B.A.

Editorials

494 Tick Distribution in South Carolina

Arthur F. DiSalvo, M.D.

495 Regionalized Perinatal Care: The Next Step

C. Warren Derrick, Jr., M.D.

Features

497 Auxiliary Page

495 Letter to the Editor

496 On The Cover
455 President’s Page

Association

489 Gray Matter

473 SCMA Newsletter

THE JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3 1 39) — Published monthly by the South Carolina
Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 1 1 188 Capitol Station,
Columbia, SC 2921 1.

Copyright © 1 989 by the South Carolina Medical Association. All rights reserved. The views expressed in this publication arc those of the writers
and do not necessarily reflect the opinions of the South Carolina Medical Association.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class
postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box
11188, Columbia, South Carolina 2921 1.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188
Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia,
Editor Emeritus

Charles N. Still, M.D., Columbia
Thomas M. LeLand, M.D., Charleston
W. Curtis Worthington, Jr., M.D., Charleston
Arthur F. DiSalvo, M.D., Columbia
Frederick L. Greene, M.D., Columbia
Albert Cannon, M.D., Charleston
J. Sidney Fulmer, M.D., Spartanburg
Hunter R. Stokes, M.D., Florence
E. Conyers O'Bryan, M.D., Florence
Robert Mallin, M.D., Columbia
William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House
Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate
Donald G. Kilgore, Jr., M.D., Delegate
Randolph D. Smoak, Jr., M.D., Delegate
Charles R. Duncan, Jr. , M.D., Alternate
J. Gavin Appleby, M.D., Alternate
Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

456

The Journal of the South Carolina Medical Association

Rising health care costs are of great concern to both health care providers and consumers alike. The reduction
of health care expenditures must occur but in a manner so as not to jeopardize the quality of care available to
patients.

Upon taking the office of the presidency of the South Carolina Medical Association in April of this year, I
stressed three primary points to my colleagues in my inaugural address: first, to provide quality medical care for
the sick; second, to discipline ourselves to insure that quality; and third, to be an observer and spokesman for
health care and guarantee access to quality care for all Americans.

Each of these responsibilities addresses the issue of quality of care for our patients. I believe it is the
responsibility of organized medicine to protect the availability of quality care for our patients from the
bureaucratic attempts to control health care expenditures.

One area of health care spending of utmost concern today is Medicare — a federal promise to provide health
care services which was made to elderly Americans 26 years ago.

Certainly, no one would quarrel with the idea of controlling Medicare costs, but the proposal to impose
expenditure targets (ETs) on Medicare payments is very simply wrong. The idea of capping the total amount of
Medicare dollars available each year is a “solution” which would work a great hardship on patients by severely
restricting their access to necessary medical services. What Congress and the Bush Administration are talking
about is RATIONING of health care. Due to new technology and longer life span, the demand for health care is
growing. To couple that demand with shrinking resources would put an unbearable pressure on physicians to
do less for patient welfare. Under ETs, the government would be asking physicians to figure out how NOT to
treat their patients instead of how to treat them. This is a situation physicians could never accept. By any name,
expenditure targets are simply an attempt by Congress and the current administration to balance the budget on
the backs of America’s elderly.

The real message of ETs is that the government cannot control the Medicare program. There are many areas
that could be considered to decrease Medicare costs. Instead of reasoned approaches to specific problem areas,
the government is throwing up its hands and abdicating responsibility to a process that has resulted in rationed
care in other countries. For example, the Canadian system progressed from access to care for everyone to long
waiting periods for hip prostheses, coronary bypass and other procedures. We are seeing America go through
the same process with Medicare. With Congress’ proposed ETs we have now reached the final step to rationing
care as we have seen in the socialized systems.

Ironically, these targets aren’t even necessary. The Ways and Means Health Subcommittee has already met
its Graham-Rudman-Hollings target for 1990, so there is no short-term justification for Medicare expenditure
targets.

The reason Part B (physician) payments have risen faster than Part A (hospitals) is not because of
“overutilization” by physicians. When the government clamped down on hospital admissions five years ago,
more procedures had to be done on an outpatient basis, resulting in an average growth of outpatient services of
30 percent per year. In comparison, physician services grew only 13 percent from 1980 to 1988. Outpatient
charges grew from 18 percent of Part B spending in 1984 to 28 percent in 1988. At the same time, physician
services decreased from 72 percent of Part B spending to 61 percent.

In commenting on ETs, a June editorial in The Washington Post concluded that “normally, it would be
wrong to impose a change as vast as this in the budget process, where the focus is on the short term rather than
the long and less on substance than on dollars.” We believe this would always be wrong.

The South Carolina Medical Association and American Medical Association believe that areas such as
practice guidelines would be more appropriate — and more effective — than ETs in controlling physicians’
charges. The number of practice guidelines in existence today is small, but there are enough of them to
demonstrate their usefulness in reducing the cost of medical care. Practice guildelines work. More importantly,
they control costs by reducing the amount of inappropriate care. On the other hand, however, expenditure
targets control costs by limiting appropriate as well as inappropriate care.

The SCMA and AMA are committed to working with Congress to address budget requirements, while
maintaining the promise of the access to quality care for all patients. Rationing in the guise of expenditure
targets would betray that promise. Physicians will not abandon their role as the patients’ advocate in order to
provide the government a quick and dirty fix to a budget problem which neither the elderly nor the physicians
created. .

Daniel W. Brake, M.D.

VOLUME 85
NOVEMBER 1989
NUMBER 11

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Original Scientific Articles

503 Intravenous Streptokinase Therapy for Acute
Myocardial Infarction in a Community Hospital:
Effect on Ventricular Function and Mortality

Joseph L. Trask, M.D., Neil W. Trask, III, M.D., William
J. Cushing, M.D., Harvey E. Butler, Jr., M.D., Bruce W.
Usher, M.D.

509 Schizophrenia: Promising New Directions in
South Carolina

Alberto B. Santos, Jr., M.D., Paul A. Deci, M.D.

522 Dynamic Auscultation

Richard S. Pollitzer, M.D., Stephen L. Watkins, M.D.,
Timothy S. Llewelyn, M.D.

Special Articles

527 Online Information Management: Who Needs It?

Nancy C. McKeehan, M.S.L.S.

529 Access to Online Information: The Hardware
Connection

Nancy Smith, M.L.S.

Editorials

533 Into The Fray: The Community Hospital
Treatment of Acute Myocardial Infarction

E. Conyers O'Bryan, Jr., M.D.

534 SCHIN and GRATEFUL MED (or Computers to
the Rescue!)

Charles S. Bryan, M.D.

Features

539 Auxiliary Page

535 On the Cover
501 President’s Page

Association

531 Gray Matter

536 In Memoriam

537 Physicians’ Advocacy and Assistance Committee
517 SCMA Newsletter

THE JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina
Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station,
Columbia, SC 29211.

Copyright © 1989 by the South Carolina Medical Association. All rights reserved. The views expressed in this publication are those of the writers
and do not necessarily reflect the opinions of the South Carolina Medical Association.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class
postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box
11188, Columbia, South Carolina 29211.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188
Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia,
Editor Emeritus

Charles N. Still, M.D., Columbia
Thomas M. LeLand, M.D., Charleston
W. Curtis Worthington, Jr., M.D., Charleston
Arthur F. DiSalvo, M.D., Columbia
Frederick L. Greene, M.D., Columbia
Albert Cannon, M.D., Charleston
J. Sidney Fulmer, M.D., Spartanburg
Hunter R. Stokes, M.D., Florence
E. Conyers O'Bryan, M.D., Florence
Robert Mallin, M.D., Columbia
William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House
Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

DELEGATES TO THE AMA

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

502

The Journal of the South Carolina Medical Association

HUGO VS. SOUTH CAROLINA

Hurricane Hugo hit the coast of South Carolina on Thursday, September 21 and struck a fierce
blow to our state that night. The word “devastating” has been used so much that we are tired of it,
but it certainly describes Hugo’s effect on South Carolina. After the shock, we started to put our lives
back together.

My medical office now has electricity and we are getting back to normal at work, but I still have 1 4
trees on my garage, deck and house and no electricity at home. I must admit that the SCMA has been
pushed down on my priority list since Hugo. I had to cancel a trip to Washington the week of
October 6 but I resumed my duties the following week, with a trip to Georgetown on October 9, and
on to Hickory Knob to meet with the House Labor, Commerce and Industry Committee, and then
the Pickens County Medical Society on October 10. Because of the magnitude of the effects of the
hurricane, I think it is certainly appropriate to dedicate this President’s Page to Hugo.

I would like to commend the doctors, nurses, paramedics, emergency personnel, electricians and
telephone personnel who neglected their personal needs to give their time to the rest of us. Many
physicians and medical personnel have gone out to rural areas to care for the sick and injured. As a
result of Hugo, our interpersonal relationships have undergone changes. For example, Hugo has
made us more honest. If you ask someone, “How are you doing?” most people would reply, “Fine,”
pre-Hugo days. Now they say, “Not so good,” “It’s getting better,” “I got electricity today,” or “Not
worth a damn.” I have noticed a definite improvement in attitudes and spirit when the electricity
comes on and you can take a hot shower and shave. I’m still waiting. I complained to a doctor in the
hospital about my problems and his answer was, “I knew a man who complained because he had no
windows until he met a man with no walls.” I stopped complaining.

This hurricane has certainly brought a lot of us closer together. We have seen neighbors working
to help each other clean their yards, when before Hugo they did not even know each other’s names.
With no electricity — therefore no television — and a curfew, our families have had to stay in and talk
to one another, resulting in closer family relationships. Disasters frequently bring out the best in us.
We have seen a tremendous outpouring of supplies and money from all over the country. It has
reinforced my belief that we are better off caring for ourselves than depending on government to
care for us. A typical example is the 38 truckloads of goods donated by private sources and delivered
to McClellanville, while the government (FEMA) tried to figure out how to get money from
Washington to the needy people in South Carolina. They still haven’t figured it out! It’s quite
obvious that whether we are talking about medicine or a disaster like Hugo, the more we care for
ourselves with as little government involvement as possible, the better off we are.

We realize that a number of physicians have lost their offices and are having financial problems as
a result of Hugo. The SCMA has offered $500,000 to set up low interest loans to needy physicians,
and the AM A is providing an additional $500,000. If you are having financial problems as a result of
Hugo, send your application in to the South Carolina Medical Association and we will try to assist
you.

I’m happy to report that, although badly damaged, Charleston has not lost its charm. The spirit I
see in the people all over South Carolina assures me that Charleston and the other areas will rebuild.
Charleston has withstood revolutionary and civil wars, fire and earthquake, and it will certainly
withstand Hugo. So you can count on our Annual Meeting, April 1990, in Charleston. All in all,
Hugo struck a mighty blow, but South Carolina will come back stronger than ever, having learned
another lesson from nature. ^

Daniel W. Brake, M.D.

President

VOLUME 85
DECEMBER 1989
NUMBER 12

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Editorials

Original Scientific Articles

549 The Surgical-Prosthetic Method of Cleft Lip and
Palate Care: Development of a Comprehensive
Program

Robert F. Hagerty, M.D., Richard C. Hagerty, M.D.,

Warren L. Gould, M.D., and the Staff of the Carolina Cleft
Lip and Palate Center

554 Identification and Intervention for Alcohol
Abuse

Stephen Holt, M.B.

560 Recurrence of Node-Negative Breast Cancer in
Patients Treated in a Community Hospital

Betty M. Hahneman, M.D., M.P.H., Shirley J. Thompson,
Ph.D., William H. Babcock, M.D., Susan Salters, B.A.,
C.T.R.

577 Trends in Public Knowledge and Attitudes
about AIDS, South Carolina, 1987-1988

Jeffrey L. Jones, M.D., M.P.H., Daniel T. Lackland,
M.S.P.H., Lynda D. Kettinger, M.P.H., William B. Gamble,
Jr., M.D., M.P.H.

580 Peace and Good Will

Charles S. Bryan, M.D.

582 Tackling the Alcohol Problem: The Case for
Secondary Prevention

Stephen Holt, M.B.

Features

589 Auxiliary Page
587 On The Cover
545 President’s Page

Association

573 CME Calendar

585 Gray Matter

590 Index to Volume 85

586 Physician Recognition Awards
565 SCMA Newsletter

Copyright © 1 989 by the South Carolina Medical Association. All rights reserved. The views expressed in this publication are those of the writers
and do not necessarily reflect the opinions of the South Carolina Medical Association.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class
postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box
11188, Columbia, South Carolina 29211.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188
Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia,
Editor Emeritus

Charles N. Still, M.D., Columbia
Thomas M. LeLand, M.D., Charleston
W. Curtis Worthington, Jr., M.D., Charleston
Arthur F. DiSalvo, M.D., Columbia
Frederick L. Greene, M.D., Columbia
Albert Cannon, M.D., Charleston
J. Sidney Fulmer, M.D., Spartanburg
Hunter R. Stokes, M.D., Florence
E. Conyers O’Bryan, M.D., Florence
Robert Mallin, M.D., Columbia
William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House
Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

DELEGATES TO THE AMA

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

546

The Journal of the South Carolina Medical Association

WE OWE IT TO FUTURE GENERATIONS

In a previous President’s Page, I told you about Healthcare 2000, our committee to address the
healthcare crisis. To treat our diseased healthcare system I have asked the members of Healthcare
2000 to take off their special interest hats and do what’s best for America. Healthcare 2000 is looking
at all aspects of the healthcare system, Medicare, Medicaid, the uninsured and the inadequately
insured.

Medicare and Medicaid account for over 50 percent of our hospital days and do not pay a full
dollar for the dollar of services received. Another 10 to 15 percent of hospital days are used by the
uninsured and inadequately insured. Obviously, they are not paying in full for the services received.
That leaves only 35 percent of patients paying in full the services received as well as picking up the
cost of services received by Medicare/Medicaid, the uninsured, and the inadequately insured.
Healthcare 2000 is addressing the healthcare issue by dividing it into two areas: (1) addressing the
total cost of healthcare by trying to discover ways to control the cost without affecting the quality of
care; and (2) redistributing the healthcare dollar so that everyone is paying what they can afford to
pay and letting the government take care of those patients that are unable to pay for themselves. One
thing is clear, it is important that the government programs pay in full for the services received so
that we can stop the burden of cost shifting to that 35 percent of patients who are paying in full.

On future President’s Pages I will discuss other aspects of our healthcare system, but for this page I
would like to take a look at Medicare. In America we find retired parents who are financially secure
offering assistance to their children. We also find children offering financial assistance to their
parents. This is the way our American system works. But with Medicare, we have wealthy parents
receiving benefits while some young people in financial trouble are having to pay for the cost
shifting in Medicare. One solution to this problem is to require everyone with the financial means to
pay their fair share of healthcare costs. This would require a means test in Medicare to put it on the
road to becoming fiscally sound. Medicare should also start paying in full for the services received
and thus eliminate the cost shift.

I really do not believe the U. S. Congress realizes the burden they are putting on future
generations of Americans when they approve more Medicare benefits without increased contribu-
tions to Medicare. Certainly refinancing Medicare will not solve all the problems but it would go a
long way toward alleviating them. We all need to work together to correct the inequities in our
healthcare system. Medicare is only one of the problems.

Daniel W. Brake, M.D.
President

December 1989

545

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION
VOLUME 85 JANUARY 1989 NUMBER 1

PROFESSIONAL LIABILITY IN SOUTH CAROLINA

INTRODUCTION

This issue of The Journal of the South Carolina
Medical Association is a milestone for the South
Carolina Medical Association/Joint Underwriting
Association Risk Management Program. Members
of the committee who have contributed so much
over the past six or more years have provided
articles for this publication. Our hope is that it will
be a permanent record or manual of the accom-
plishments of what those of us involved believe is a
very successful endeavor. The thrust of the pro-
gram has always been and continues to be
positive. The concept of the program originated
in the minds of thinkers and doers in our Associa-
tion. We were faced with a pending crisis in
medical liability — everyone told us we were just
behind the rest of the country but that the prob-
lem would overtake us and we would be in trouble
just as Florida, New York, California and others
were.

When all the malpractice insurers pulled out of
the state in the mid 70’s, SCMA leadership worked
with the South Carolina General Assembly and
the Joint Underwriting Association was created.
Later the Patients’ Compensation Fund was es-
tablished. These are relatively permanent entities,
being functional until there is “no longer a need
for them.”

The JUA and the PCF have very adequately
met the needs of South Carolina physicians as well
as other healthcare providers. SCMA tried once to
bring a private insurer back into the state but this
carrier could not compete with the JUA’s rate
structure and soon pulled out.

There has been good and helpful cooperation

GUEST EDITORS
PROFESSIONAL LIABILITY IN
SOUTH CAROLINA

EUTA M. COLVIN, M.D.
WILLIAM L. FAIREY, M.D.
JOHN R. HUNT, M.D.
ROLAND L. SKINNER, JR., M.D.
BARTOLO M. BARONE, M.D.
B. DANIEL PAYSINGER, M.D.
JOHN W. BROWN, M.D.

from the state Insurance Department through the
Commissioners, John Lindsey, Roger Smith and
now John Richards. SCMA, as well as other health
professional groups, is well represented on the
Board of Directors of both the JUA and the PCF.

This special issue of The Journal of the South
Carolina Medical Association is dedicated to the
many individuals who have contributed to the
success of our medical liability efforts in South
Carolina — to the leadership of SCMA, the South
Carolina General Assembly, the South Carolina
Insurance Department, JUA Defense Attorneys
and UAC Investigators, the staff of the South
Carolina Medical Association, the Physicians Risk
Management Committee and particularly to the
many South Carolina physicians who have given
freely and willingly of their time and abilities.

With this support our efforts will continue to
“eliminate the negative” and “accentuate the
positive” in medical professional liability in South
Carolina. □

January 1989

GLANCING BACK

WILLIAM F. FAIREY, M.D.*

It is of historical interest that a “Medical Mal-
practice Survey” was taken of the South Carolina
physicians in 1971 by this author, who reported
the results in The Journal of the South Carolina
Medical Association in January 1972. The closing
paragraphs of this article are as follows:

“As a result of this survey and its conclusions, it
would seem appropriate at this time for orga-
nized medicine in South Carolina to form a
“Malpractice Committee” to avail themselves
of the status of malpractice cases and insurance
as revealed by this study, to keep abreast of
increased rates as are periodically requested by
the insurance companies and for represen-
tatives of the Committee to attend such open
hearings as are made available by law to ques-
tion critically the basis for such increases; to
determine some means of notification by the
insurance companies of the outcome of each
malpractice claim or case which is brought in
South Carolina; and further to consider the
possibilities of obtaining a single insurance
company which would offer to insure the phy-
sicians of South Carolina in a fair, consistent
and realistic manner, and by this pooling of
malpractice data, information can be readily
and constantly available as the malpractice sit-
uation predictably becomes more critical.

Consideration may even be given to the for-
mation of a panel of physicians (or doctors and
lawyers) to evaluate on behalf of the individual
doctor against whom a claim is made to deter-
mine whether it is a valid claim as has been
done in other states with the cooperation of an
insurance company. In this way, the insurance
company can keep its doctors constantly alerted
to the pitfalls and can provide prophylactic
measures by which the physician can avoid
legal entanglements.

Education of the physician is needed by hav-
ing nationally recognized legal experts to speak
to the Medical Association and to the county

societies, by formation of medical-legal panels
locally to discuss their respective disciplines
and to seek common ground of understanding.
It is to be noted that the Medical College has
adopted as a part of its new curriculum a re-
quired 22 hour course on medical jurispru-
dence which stimulates the students early so
that they pursue a continual, interested study of
malpractice cases throughout their training, on
a sound and relatively objective basis.

Although the malpractice picture in South
Carolina has not reached the critical stage, as
one reads the individual letters from the physi-
cians who have been threatened or involved in a
malpractice suit, the only conclusion is that the
situation is serious enough and potentially dan-
gerous enough to warrant an official interest by
organized medicine in this State. The goal at
the present time should be primarily that of
finding a means by which the physicians might
stay informed on a year to year basis as to what
malpractice suits are being brought and to be
reassured that the rates are reasonably tied in
with the malpractice experience.”

During the past 17 years, organized medicine
has responded well to the concerns expressed by
the physicians in this 1971 survey. The physicians’
survey reflected a certain helplessness, dismay,
and even outrage relative to their plight and to the
discernable malpractice crisis which was begin-
ning to unfold.

Due to enlightened leadership of the South
Carolina Medical Association, uniquely bringing
together the strengths of the state government
combined with that of the insurance industry,
South Carolina has responded well to the chal-
lenge of the medical malpractice crises of the 70 s
and 80 s. As a profession and as an association, it is
vital that we continue to work together to address
the medical malpractice problems/crises as they
arise in the coming years. □

P. O. Box 188, Pawleys Island, SC 29585.

6 The Journal of the South Carolina Medical Association

SOUTH CAROLINA MEDICAL MALPRACTICE
JOINT UNDERWRITING ASSOCIATION

BARTOLO M. BARONE, M.D.*

In early 1974 and in 1975, the private insurance
carriers announced they would no longer write
medical malpractice coverage in South Carolina.
Consequent to this impending availability crisis,
the South Carolina Medical Association worked to
maintain an occurrence basis rather than a claims-
made market for professional liability insurance.
Through the expert help of Mr. Calvin Stewart
and the South Carolina Department of Insurance,
the SCMA appealed to the legislature for the
enabling legislation, and the South Carolina Medi-
cal Malpractice Liability Joint Underwriting As-
sociation came into being in 1975, with Mr. Calvin
Stewart as the Manager and the Chief Insurance
Commissioner of the South Carolina Department
of Insurance as the Chairman of the JUA Board.

Only three major changes have been made in
the JUA law during its entire lifetime. The first
major change in 1976 removed the provision
which made the JUA the exclusive medical mal-
practice insurer in South Carolina, and this
change permitted the private insurance com-
panies to sell medical malpractice insurance in
South Carolina. The second major change also
occurred in 1976 when the JUA law was changed
to limit the amount of coverage provided by the
JUA to $100,000 per claim and $300,000 aggre-
gate of all claims in one year. This change made
the JUA a basic insurer and the Patients’ Compen-
sation Fund (PCF) became the source of the ex-
cess medical malpractice coverage. The third
major change occurred in 1983 when the JUA law
was changed to make the JUA a permanent opera-
tion. Prior to this time the JUA law expired every
year or two and it was necessary to pass new
legislation to extend the JUA’s authorization to
operate. With the exception of these three
changes, the JUA currently operates as it did in
the beginning on July 1, 1975.

The JUA operates exactly like a mutual insur-
ance company in that it provides all of the casu-

° 315 Calhoun St., Charleston, SC 29401.

alty insurance services that are provided by
insurance companies. The JUA issues insurance
policies, collects and invests insurance premiums,
handles claims, defends suits and provides loss
control and risk management services to its pol-
icyholders. The JUA operates under the direction
of its Board of Directors and through the JUA
manager and servicing carriers. The Board con-
tracts with the servicing carriers to provide the
necessary policy, claims, loss control and risk man-
agement functions. This has proven to be a very
satisfactory and economical method of operation.
Most private insurance companies’ total expenses
are at least 30% of each premium dollar while the
JUA’s total expenses are less than 15% of each
premium dollar. The JUA is able to specialize in
specific areas in a manner that private insurers are
unable to do in that it contracts with the South
Carolina Medical Association to provide a very
comprehensive physician risk management pro-
gram and it contracts with the South Carolina
Hospital Association to provide an extensive hos-
pital loss control program. The JUA is also able to
contract with a company which specializes in
claims and a company which specializes in policy
administration.

The JUA was the exclusive medical malpractice
insurer from July 1, 1975 through September 27,
1976 and insured all of the nongovernment physi-
cians during this period. Although private insur-
ance companies started to insure South Carolina
physicians again on July 1, 1977, the private insur-
ance companies have never made any significant
market penetration and the JUA has been the
state’s major medical malpractice insurer since its
inception. The JUA currently insures more than
three thousand physicians and a thousand P.A.s.
There are a number of reasons for the JUA’s
popularity with physicians including occurrence
type coverage at an affordable cost, good service,
and strong legal defense; however, the most
important reason is the physicians’ confidence in
the JUA. As a result of the very extensive physi-

January 1989

THE JUA

cian participation in the operation of the JUA,
physicians are aware of the true medical malprac-
tice conditions in South Carolina and the neces-
sary costs of insuring South Carolina physicians
for their medical malpractice exposures. Not only
do our physicians know that the JUA is being
operated in their best interests, they also know
that no one will make a profit from its operation.
They know that the JUA will continue to be
available to them and that physicians will con-
tinue to have a major role in the operation of the
JUA.

It is quite clear that the medical malpractice
crisis of the seventies is still with us in the eighties
and that it will probably be with us for a long, long
time in the future. Most states have passed a
tremendous amount of legislation in an attempt to
improve the medical malpractice conditions.
Some 37 states have passed very extensive medical
malpractice tort reform laws and there has been
no measurable improvement. In fact, medical
malpractice conditions seem to be getting worse
in many parts of the country. For example, Vir-
ginia and Minnesota have activated JUAs in the
last year or so and recently the last two major
medical malpractice private insurance companies
pulled out of Kansas. The private insurer market is
extremely restricted here in South Carolina and
the major private insurance company has not
insured any new physicians, except new members
of insured groups, for over two years. Along with
the restricted availability of medical malpractice
insurance here and in other states, there has been a
tremendous increase in the cost of medical mal-
practice insurance. While South Carolina’s in-
creases have been substantial (class I rate in 1975

was $250 and class I rate in 1988 is $1,226), our
state has not experienced increases which com-
pare with the increases in other states. We are all
familiar with the horror stories of $100,000 or
$200,000 annual malpractice premiums for physi-
cians in Florida and New York; however, you may
not be aware of the fact that in 1987 a Georgia
OB-GYN paid five times as much for $1,000,000
claims made coverage than a South Carolina OB-
GYN paid for unlimited occurrence coverage
through the JUA and PCF. The North Carolina
OB-GYN paid almost three times more than his
South Carolina counterpart and only has
$1,000,000 claims made coverage. There is no
question that South Carolina medical malpractice
costs are among the lowest in the entire country.

In an effort to determine why South Carolina
enjoyed this favorable medical malpractice posi-
tion among the various states, comparisons were
made in the medical malpractice insurance opera-
tions in other states with JUAs and physician
owned medical malpractice insurance companies.
The only factor which could be identified as being
different is the extensive and direct involvement
of physicians in the entire South Carolina medical
malpractice process. Physicians serve on the JUA
and PCF Boards and Committees as well as the
Physician Risk Management Committee. Over
1,000 South Carolina physicians participate in the
Physician Risk Management program. Credit for
South Carolina medical malpractice success must
go to all of the South Carolina physicians and
particularly to the leaders of the South Carolina
Medical Association who had the foresight to de-
velop the JUA and the PCF and the fortitude and
persistence to make them work. □

The Journal of the South Carolina Medical Association

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January 1989

SOUTH CAROLINA MEDICAL MALPRACTICE
PATIENTS' COMPENSATION FUND

DONALD G. KILGORE, JR., M.D.*

C. TUCKER WESTON, M.D.**

In 1975 the South Carolina General Assembly
passed legislation which created the South Caro-
lina Medical Injury Insurance Reparations Ad-
visory Committee to perform a comprehensive
study of medical malpractice conditions in South
Carolina and to recommend remedial legislation
to improve these conditions. This was a Blue Rib-
bon committee whose 17 members included sen-
ators, representatives, physicians, dentists, hospi-
tal officials, defense attorneys, plaintiff attorneys,
insurance agents and members of the general
public. This committee was jointly chaired by
Chief Insurance Commissioner John W. Lindsay
and the Commissioner of Health & Environmen-
tal Control, E. Kenneth Aycock, M.D. The Com-
mittee drafted proposed legislation creating the
PCF which was adopted by the General Assembly
in 1976. The PCF became operational on July 1,
1977.

The PCF operates in a manner similar to an
excess insurance company and provides unlimited
coverage that is identical to the basic malpractice
insurance. The PCF does not provide any of the
malpractice insurance services; it does not issue
policies since it actually extends the limits of cov-
erage of the basic malpractice insurance policy; it
does not handle claims or defend suits since the
PCF law requires the basic insurer “to provide an
adequate defense on any claim filed that poten-
tially affects the Fund;’’ nor does the PCF provide
any loss control or risk management services
which are provided by the basic insurer. The
PCF’s function is to monitor potential claims and
to make payments on settlements which it consid-
ers to be appropriate or to pay its share of court
awards.

The PCF operates under the direction of a
Board of Governors and through the PCF staff.
PCF members deal directly with the PCF staff

° 8 Memorial Medical Ct., Greenville, SC 29605.
P. O. Box B, Columbia SC 29202.

and no other organizations or agents are involved
in the PCF’s operation. The PCF is able to operate
with a very small staff and the total operation costs
of the PCF are approximately two percent of its
revenues. This means that over 98% of each PCF
fee dollar goes into the state treasury where it
earns interest until such time as it is needed to pay
claims. The PCF is totally funded by its members.

Economy is only one of the important features
of the PCF. The low cost of protection is very
important; however, the amount of protection
provided by the PCF may be even more impor-
tant. The PCF provides unlimited coverage in
excess of the member s basic malpractice insur-
ance. This extensive protection is particularly
important in the many claims which involve sev-
eral permanent injuries and huge expenses. The
unlimited coverage provides the PCF member
with the opportunity to defend himself without
jeopardizing his personal assets. Since the entire
costs of the PCF are shared by all PCF members,
the individual PCF member’s exposures are
spread over the entire PCF membership of over
4,600 physicians, dentists, hopsitals and others.
This broad spread of risk reduces everyone’s per-
sonal risk while they enjoy the maximum protec-
tion. Some question thas been raised as to the
feasibility of unlimited coverage and actuarial
studies were made to determine the cost of lower
amounts of coverage. When this study showed
that a PCF coverage limit of $5,000,000 would
only result in a six percent savings, the PCF Board
of Governors did not feel a reduction of coverage
was worthwile.

One of the most misunderstood provisions of
the PCF law is the optional payment provision
which permits the PCF Board to pay as little as
$100,000.00 per claim per year. Some have inter-
preted this provision to mean that the PCF could
only pay $100,000.00 per year on any claim. This
is completely incorrect and there is no limitation
on the amount the PCF can and will pay on any

The Journal of the South Carolina Medical Association

claim. Since the PCF is responsible to the PCF
member for the entire amount of the award which
is in excess of the basic medical malpractice insur-
ance, plus 14% interest on the unpaid award, it is
not in the PCF’s best interest nor the members’
best interest for the PCF payment to be limited to
$100,000.00 per year if the PCF has the money to
pay the award. The PCF has never paid less than
the entire award during its eleven plus years of
operation. At one time the size of the PCF was
limited to four million dollars and the danger of
depletion of the entire fund was real. Now the
PCF has more than $23 million in the state treas-
ury plus the ability to raise much more if neces-

sary, and there is no reason to be concerned with
the PCF’s ability to deal with a large award.

After more than eleven years of operation, the
PCF has proven to be successful beyond all expec-
tations. It is providing unlimited medical mal-
practice protection to the great majority of South
Carolina physicians, hospitals and dentists and the
cost of this protection is remarkably low. This is
essentially a “do it yourself” organization and its
success is the result of the extensive involvement
and support of the state’s physicians and particu-
larly the current and former leaders of the South
Carolina Medical Association. □

JUA CLAIMS FUNCTIONS

BOYCE M. LAWTON, JR., M.D.*

WHAT HAPPENS WHEN A CLAIM IS
RECEIVED BY THE JUA?

Initially, it is referred to UAC (Underwriters
Adjustment Corp.), our claims administrators,
who do the initial investigative work. This is usu-
ally accomplished in the first 30 days. Their find-
ings determine how the claim will be handled:

(1) A decision may be made to engage an at-
torney for the defendant. JUA manager,
Cal Stewart, is primarily responsible for
selection of the lawyer, from a list of expert
defense lawyers;

(2) UAC may decide to do nothing and await
developments, especially if they feel claim
is non-meritorious; or

(3) UAC may push for resolution when the
claim is highly defensible.

Our claims administrators will oversee progres-
sion of the case and assist in settlement if
indicated.

Legally, your JUA policy gives the JUA author-
ity to select the defendant lawyer. Traditionally,
we have frequently acquiesced and permitted the
defendant to use the lawyer of his choice if he had

strong feelings about the matter. Recently, we
have initiated a new policy of selecting the lawyer
we feel can achieve the best results, regardless of
where the defendant and lawyer live in the state.

Our claims committee’s main function is to
insure the adequacy of reserves for pending cases
and cases in suit. Files are periodically reviewed
by our committee.

During the course of our review, we occasion-
ally come upon instances of gross negligence,
and/or individuals with multiple claims. These
individuals are reported to the S.C. Board of Med-
ical Examiners. They, in turn, initiate their own
investigation to determine if any of the Medical
Practice Laws of South Carolina or Rules and
Regulations of the State Board of Medical Exam-
iners have been broken.

We feel we have a very aggressive defense,
skilled and dedicated claims people and excellent
defense attorneys which have resulted in our win-
ning 91% of our suits over the last three years and
97% in 1987. " □

° P.O. Box 366, Cameron, SC 29030.

January 1989

YOCON

YOHIMBINE HCI

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxytic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its
action on peripheral blood vessels resembles that of reserpine, though it is
weaker and of short duration. Yohimbine’s peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.

Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug . Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone.

Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it; however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.

Indications: Yocorr is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac.

Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications.

Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history. Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.12 Also dizziness,
headache, skin flushing reported when used orally.13
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence. 1 '3 4 1 tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to Vi tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of YoconT 1/12 gr. 5.4 mg in
bottles of 100’s NDC 53159-001-01 and 1000’s NDC
53159-001-10.

References:

1. A. Morales et al., New England Journal of Medi-
cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed., p. 176-188.

McMillan December Rev. 1/85.

3. Weekly Urological Clinical letter, 27:2, July 4,

1983.

4. A. Morales et at. , The Journal of Urology 1 28:

45-47, 1982.

Rev. 1/85

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^^(sucralfate) Tablets

BRIEF SUMMARY

CONTRAINDICATIONS

There are no known contraindications to the use of sucralfate.

PRECAUTIONS

Duodenal ulcer is a chronic recurrent disease. While short-term treatment
with sucralfate can result in complete healing of the ulcer a successful course
of treatment with sucralfate should not be expected to alter the post-healing
frequency or severity of duodenal ulceration.

Drug Interactions: Animal studies have shown that simultaneous admin-
istration of CARAFATE (sucralfate) with tetracycline, phenytoin, digoxin, or
cimetidine will result in a statistically significant reduction in the bioavailability
of these agents. The bioavailability of these agents may be restored simply by
separating the administration of these agents from that of CARAFATE by two
hours. This interaction appears to be nonsystemic in origin, presumably result-
ing from these agents being bound by CARAFATE in the gastrointestinal tract
The clinical significance of these animal studies is yet to be defined. However
because of the potential of CARAFATE to alter the absorption of some drugs
from the gastrointestinal tract the separate administration of CARAFATE from
that of other agents should be considered when alterations in bioavailability
are felt to be critical for concomitantly administered drugs.

Carcinogenesis, Mutagenesis, Impairment of Fertility: Chronic oral
toxicity studies of 24 months' duration were conducted in mice and rats at
doses up to 1 gm/kg (12 times the human dose). There was no evidence of
drug-related tumorigenicity. A reproduction study in rats at doses up to 38
times the human dose did not reveal any indication of fertility impairment
Mutagenicity studies were not conducted.

Pregnancy: Teratogenic effects. Pregnancy Category B. Teratogenicity
studies have been performed in mice, rats, and rabbits at doses up to 50 times
the human dose and have revealed no evidence of harm to the fetus due to
sucralfate. There are, however, no adequate and well-controlled studies in
pregnant women. Because animal reproduction studies are not always pre-
dictive of human response, this drug should be used during pregnancy only rf
clearly needed.

Nursing Mothers: It is not known whether this drug is excreted in
human milk. Because many drugs are excreted in human milk, caution should
be exercised when sucralfate is administered to a nursing woman.

Pediatric Use: Safety and effectiveness in children have not been
established.

ADVERSE REACTIONS

Adverse reactions to sucralfate in clinical trials were minor and only rarely led
to discontinuation of the drug. In studies involving over 2,500 patients treated
with sucralfate, adverse effects were reported in 121 (4.7%).

Constipation was the most frequent complaint (2.2%). Other adverse effects,
reported in no more than one of every 350 patients, were diarrhea, nausea,
gastric discomfort, indigestion, dry mouth, rash, pruritus, back pain, dizziness,
sleepiness, and vertigo.

OVERDOSAGE

There is no experience in humans with overdosage. Acute oral toxicity studies
in animals, however, using doses up to 1 2 gm/kg body weight could not find a
lethal dose. Risks associated with overdosage should, therefore, be minimal.

DOSAGE AND ADMINISTRATION

The recommended adult oral dosage for duodenal ulcer is 1 gm four times a
day on an empty stomach.

Antacids may be prescribed as needed for relief of pain but should not be
taken within one-half hour before or after sucralfate.

While healing with sucralfate may occur during the first week or two,
treatment should be continued for 4 to 8 weeks unless healing has been
demonstrated by x-ray or endoscopic examination.

HOW SUPPLIED

CARAFATE (sucralfate) 1-gm tablets are supplied in bottles of 100 (NDC
0088-171 2-47) and in Unit Dose Identification Paks of 1 00 (NDC 0088- 1 71 2-49).
Light pink scored oblong tablets are embossed with CARAFATE on one side
and 1 71 2 bracketed by C's on the other. Issued 1 /87

Reference:

1 . Eliakim R, Ophir M, Rachmilewitz D: J Clin Gastroenterol 1987, 9{A):39S-399

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The Journal of the South Carolina Medical Association

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January 1989

THE SOUTH CAROLINA MEDICAL
ASSOCIATION/JOINT UNDERWRITING
ASSOCIATION RISK MANAGEMENT PROGRAM

EUTA M. COLVIN, M.D.*

Discussion regarding the establishment of a
physician’s risk management program began in
the early days of the Joint Underwriting Associa-
tion when the suggestion of this type activity was
brought before the Council of the South Carolina
Medical Association by the SCMA Professional
Liability Committee, chaired by Frank Biggers,
M.D., in early 1976. The committee had based the
idea on the fact that the South Carolina Hospital
Association had a similar program under contract
with the JUA. The SCMA Council and the Profes-
sional Liability Committee felt that the SCHA
program, while benefiting institutions, did little
for physicians covered under the JUA. It was their
consensus that a risk management program for
physicians and their office staffs was needed to
minimize professional liability risk and lessen the
volatility of the medical liability environment.

The SCMA Council studied the idea over the
next several years and the officers had various
meetings with insurance people and risk manage-
ment and loss prevention specialists, discussing
the possibility of contracting for an outside group
to handle the program, much as the South Caro-
lina Hospital Association had done. With the help
of Charlie Johnson and Blake Williams of SCMA
staff, a proposal was developed with the idea that
we could do a better job ourselves than the groups
who had presented plans to us. The conclusion
that we had the interest and the ability in the
South Carolina Medical Association’s mem-
bership, leadership and staff was enthusiastically
recognized. We were encouraged in this thinking
by Cal Stewart of the State Insurance Department
who was our staunch supporter.

I recall a meeting that the Executive Commit-
tee of Council had with the four physicians serv-
ing on the JUA Board — Boyce Lawton, John
Sutton, Bart Barone and Walt Roberts. They were

Department of Surgery, Spartanburg Regional Medical Cen-
ter, 101 E. Wood Street, Spartanburg, SC 29303.

very receptive to the idea and agreed to present it
to the JUA Board and to encourage its approval.

The proposal was presented to the Honorable
John W. Lindsey, Commissioner of the South
Carolina Department of Insurance and Chairman
of the JUA Board, in a letter from Halstead Stone
in November, 1980. There continued to be discus-
sions and encouragement and on January 8, 1982,
at a meeting of the JUA Servicing Carrier Com-
mittee, chaired by Bart Barone, acceptance of the
program was recommended to the full JUA Board
and was approved with the following objectives:

1. Four regional meetings co-sponsored by
SCMA and various county medical societies,
and one statewide meeting to be held at the
SCMA Annual Meeting.

2. Periodic newsletters on South Carolina med-
ical malpractice claims development.

3. Recruiting and maintaining a comprehen-
sive panel of physicians to review and testify
on JUA claims.

A quote from the SCMA proposal seems to be
pertinent and is as follows:

“The South Carolina Medical Association
will, on an ongoing basis, continue its efforts
for additional tort reform with hopes of as-
suring a more stable insurance marketplace
for all South Carolina health care pro-
fessionals.

The SCMA recognizes the fact that tort
reform alone will not assure the creation nor
the stabilization of the medical liability work
place. The SCMA believes that the funda-
mental natures of risk must be minimized to
lessen the volatility of the medical liability
environment.

Therefore, the SCMA would propose to
develop and administer, in cooperation with
the South Carolina Medical Practice Lia-
bility Insurance Joint Underwriting Associa-
tion, a program of risk management and loss

The Journal of the South Carolina Medical Association

SCMA/JUA RISK MANAGEMENT PROGRAM

prevention for physicians and their office
staffs.

The SCMA proposes to provide educa-
tional and informational services directed to-
ward the physicians and their office staffs in
an effort to support loss prevention pro-
grams. The SCMA is prepared to develop and
support meaningful programs in this area,
programs that should be beneficial to both
the JUA and the physician.”

The first program on risk management was
held in Charleston on April 22, 1982. The follow-
ing is a quote from the invitational letter to physi-
cians written by Frank Biggers, Chairman of the
Professional Liability Committee. “This may be
our last opportunity to have some positive effect
on this growing malpractice problem.” Subse-
quent meetings were held in Greenville, Florence
and Columbia.

The original members of the Risk Management
subcommittee were John Hunt of Anderson,
Danny Paysinger of Columbia, Roy Skinner of
Florence and Bart Barone of Charleston. Their
time was largely devoted to reviewing charts and
then locating an area physician to review in depth
and give advice concerning the defensibility of
the case. They also presented programs locally
and regionally on the subject of risk management.
They did an outstanding job and continue to do so.
John Brown of Columbia was added to the com-
mittee later because of the number of cases in the
midlands area. The author was appointed in early
1983 by Randy Smoak and was designated as
Chairman, with the objective of expanding the
project and trying to attain the original goals of
the program. Billy Fairey of Pawleys Island and
Georgetown was added to the committee about
two years ago, and he has brought considerable
expertise from both his medical and legal back-
grounds. Each of these physicians is dedicated to
the success of this effort.

The first official meeting of the SCMA/JUA
Subcommittee on Risk Management was held on
July 13, 1983, and the course of the present pro-
gram was set. A questionnaire was sent out to all
South Carolina physicians asking them to volun-
teer to serve as chart reviewers, expert defense
witnesses, moral supporters to physicians being
sued, and generally to be supportive of the pro-
gram with their suggestions. We had over 1,000

responses to that request and all were very
positive.

At that meeting, the motto of the program,
‘‘Physicians Helping Physicians,” was chosen.
Later, at a suggestion from a reader, it was
changed to “South Carolina Physicians Helping
Physicians. ” Also, plans were made to start pub-
lishing a quarterly newsletter and the first issue
came out in January, 1984. It was originally called
the “Medical Malpractice Bulletin” but at the
suggestion of one of our physicians it was changed
to “Medical Liability Bulletin,” which is much
more appropriate.

We have come a long way and I know that the
program has had a very significant beneficial
effect on the medical liability situation in South
Carolina. Much, much credit goes to Cal Stewart,
who has been our ardent supporter and very valu-
able advisor from the very beginning. Joy Dren-
nen of the SCMA staff provides outstanding
support to the program and serves as the Editor of
the Bulletin. She coordinates the program and has
much to do with its success. Previously, we had
excellent staff support from Robin Medlock and
Mary Ann West.

I also want to acknowledge the tremendous
contributions that Dr. Bill Cantey has made and
continues to make to this program. His careful
and constructive preliminary review of charts is
most helpful to our regional committee members.

SCMA/JUA RISK MANAGEMENT
PROGRAM CURRENT ACTIVITIES

— Review of malpractice claims by phy-
sicians.

— Depositions and testimony for defense.
— Publication of quarterly Risk Manage-
ment Bulletin.

— Risk Management Programs:

— Statewide
— Regional
— Medical staffs

— Medical school faculty /students
— SCMA Annual Meeting
— Lending program — audiotapes, video-
tapes

— Written materials on professional liability

January 1989

Now, with some improvement due to recent
tort reform legislation, we are encouraged to con-
tinue a full and even expanded program. Included
in the table is a listing of the activities of the
SCMA/JUA Risk Management Program. The real
success of this endeavor is due to the cooperation
of the physicians of our state, who have taken
seriously our motto, “South Carolina Physicians
Helping Physicians.” □

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THE INTERIM MEETING OF THE AMA

REPORT OF THE SCMA DELEGATION

JOHN C. HAWK, JR., M.D.

RBRVS

It was a foregone conclusion that the most important and
contentious issue at the Interim Meeting of the AMA House of
Delegates at Dallas, Texas (December 2-7, 1988) would be the
Resource Based Relative Value Scale (RBRVS) , developed by William
H. Hsiao at Harvard University, and funded through a cooperative
agreement with the Health Care Financing Administration in
response to a congressional mandate to the Secretary of Health
and Human Services. The AMA served as a subcontractor in the
Harvard Study, as described in several previous reports from the
Board of Trustees.

The Board of Trustees, in addition to a preliminary report N,
submitted to the House Report AA, a comprehensive 57-page
evaluation of the RBRVS. The report by the Harvard group had
been released on September 28, 1988, and simultaneously the
studies, methods and results were published in the New England
Journal of Medicine, with an accompanying editorial by HCFA
Administrator, William Roper, M.D. Also the entire October 28th
issue of the Journal of the American Medical Association (JAMA)
was devoted exclusively to the Harvard Study. Additional
material had been submitted in advance to the various state
associations .

At the meeting there were a total of nine resolutions which
addressed the RBRVS in one way or another. As expected,
resolutions from the American College of Physicians, the American
Society of Internal Medicine, and the American Academy of Family
Physicians asked for support of the RBRVS and development of a
gradual but definite phase-in of the program. The resolution
from the American Academy of Ophthalmology requested withholding
of any endorsement until approval of the methodology and
conclusions by the AMA House of Delegates. A resolution from Dr.
F. William Dowda asked for opposition to any implementation of
the RBRVS. A resolution from the Utah delegation stressed the
need for unity in the response to the RBRVS and also asked that
the AMA analyze the impact on availability of care, cost of care,
and the structure of the nation's health care system. The
Hospital Medical Staff Section asked for a sense of restraint and
responsibility, with a constant concern for what is best for the
patient, and also asked the AMA to work diligently to minimize
potential divisiveness. The Resident Physicians Section

CMTlO*‘

requested the AMA to study the effects of the RBRVS on funding of
graduate medical education. Finally, in a late resolution
accepted by the House, Dr. Joseph O'Donnell, delegate from
Illinois, asked that the AMA withhold endorsement of the RBRVS
until questions of its impact on patients and concerns about the
technical aspects of the study are addressed.

The issue was assigned to Reference Committee A, and the speakers
had taken the unprecedented step of arranging for Reference
Committee A to meet on Sunday afternoon with no other conflicting
meetings so that all delegates would have a chance to attend the
hearings. The committee met for over three hours on Sunday
afternoon, and then had to continue its hearings Monday morning.
There were long lines at all of the microphones, and the
testimony was diverse, conflicting, sometimes heated, and before
the end was certainly quite repetitious. There was no time
limit set on testimony, and everyone had a chance to speak.

The Reference Committee, chaired by Dr. John C. Nelson of Utah,
did a monumental job of making appropriate recommendations for
amendment of Report AA of the Board of Trustees and were highly
complimented for their diligent work. The report emphasized that
the AMA reaffirms its current policy in support -of a fair and
equitable Medicare indemnity payment schedule under which
physicians would determine their own fees and Medicare would
establish its payments for physicians' services, using an
appropriate RVS, an appropriate monetary conversion factor, and
an appropriate set of conversion factor multipliers. It was
noted that refinement and modifications of the RBRVS are
necessary and a number of the problems were detailed. It was
stated that there would have to be a blending transition period
and that this should have an appropriate balance between
minimizing disruptions for physicians and patients while also
minimizing the complexity of the process. It was reaffirmed that
this indemnity payment system should reflect valid and
demonstrable geographic differences in practice costs, including
professional liability insurance premiums. Emphasis was placed
that geographic differentials should be addressed simultaneously
with specialty differentials. Also it was felt that a method of
adjusting payments to effectively remedy demonstrable access
problems in specific geographic areas should be developed and
implemented .

Probably the most important testimony centered on the following
section which was revised to state "that the Association strongly
oppose any attempt to use the initial implementation or
subsequent use of any new Medicare payment system to freeze or
cut Medicare expenditures for physicians' services in order to
produce federal budget savings".

The House adopted Board of Trustees Report AA as amended with the
proviso that the Board report back to the House on further
developments regarding the Harvard RBRVS and other issues
considered in Report AA at the 1989 Annual Meeting or sooner if

necessary. The House also adopted an added resolution from the
Virginia delegation "that the AMA prepare at the earliest
possible date informational material regarding the significance
of the adoption of Board of Trustees Report AA" . It was
requested that this material be "positive in nature, concise,
readily understandable, and in a form suitable for presentation
at informational meetings of hospital medical staffs, local and
county medical societies, and specialty groups". The resolution
asking that the AMA study the effects of the RBRVS on graduate
education was amended to include undergraduate medical education.

I believe that nearly all delegates received a large number of
communications both before and after the Interim Meeting, from
individual physicians and societies, recommending adoption or
rejection of the RBRVS. Obviously the AMA cannot please everyone
completely. I personally believe that the final action of the
House was about as satisfactory as could be obtained.
Subsequently we received a "clean copy" of Report AA of the Board
of Trustees, as revised by the House. The internists and family
practitioners, including members of our own delegation, might
wish for immediate implementation of the RBRVS, since it would
increase payments to them. On the other hand, various surgical
specialty groups and those internists who carry out various
"procedures" would prefer that it be amended, delayed, or
completely "killed". In my opinion the House of Delegates acted
in a wise and judicious manner.

It should be noted that the House was considering tjiis matter
under the implied, and perhaps actual, threat thatr if the AMA
could not reach some sort of consensus about the RBRVS' that it
might lead Congress to adopt a much more onerous capitation plan
for all Medicare patients.

REGISTERED CARE TECHNOLOGISTS

The RCT program, which had been discussed at length at the Annual
Meeting of the AMA, was again the subject of debate both in
Reference Committee C and on the floor of the House. Testifying
to the reference committee, the representative of the American
Nurses Association indicated "that the dialogue between the AMA
and ANA on the RCT was at an impasse, but that new constructive
relationships between nursing and medicine were developing at the
state and local levels". It should be noted that the ANA
represents a relatively small percentage of all of the nurses,
probably about 20% in our own state.

Before the House was an excellent Report Z from the Board of
Trustees, describing implementation thus far of the program
adopted by the House in June. This announced the Board's
decision to evaluate one or more of the existing programs that
are most similar to the proposed RCT program and to implement a
pilot project to demonstrate and evaluate the training of RCTs.
A resolution from Florida asked that the AMA "back off" and seek
alternative proposals to the RCT program, and recognized the

concern of the ANA and other nursing organizations.

The reference committee, after hearing all testimony, provided a
substitute resolution "that the American Medical Association
continue to seek solutions to the problem of the shortage of
bedside care givers, in addition to the Registered Care
Technologists Program". Amendments from the New York delegation
would have changed the title of the resolution from "Registered
Care Technologists" to "Addressing the Nursing Shortage", would
have eliminated the above Resolved, and would have added a
Resolved which in effect asked for the AMA just to work with the
ANA and other nursing organizations. This the AMA has done for
many years, without complete success.

The motion to change the title and to delete the Resolve of the
reference committee was defeated. I personally spoke to this, as
I believe, from my personal experience as a patient, that there
is a need for additional bedside care givers, who would be of
assistance to the nurses, but would not have to have all of the
training of nurses. The House agreed with the reference
committee, but added the additional New York Resolve "that the
American Medical Association, recognizing the concerns of our
partners in health care, the nursing profession, work together
with the American Nurses ' Association and other nursing
organizations to address the nursing shortage and to continue to
seek innovative ways to alleviate the acute shortage of bedside
care providers, and that the Board of Trustees report to the
House of Delegates at the Annual Meeting in 1989". I had
received in advance a request from the President of the South
Carolina Nurses Association to try to defeat the RCT program and
had replied to her my personal feelings on this matter. The
House of Delegates apparently agreed with my thoughts that this
RTC program should be tried, as originally provided, to see
whether it will be successful or not.

ADDRESS OF THE PRESIDENT

Undoubtedly the address of Dr. James E. Davis, AMA President,
played a major role in the decision of the House to continue
implementation of the RCT program. He called the AMA-proposed
"Registered Care Technologists" an idea whose time has come and
he urged that an opportunity be given to try it out in order to
provide more bedside care givers.

In regard to the RBRVS , Dr. Davis urged physicians to "remain
unified and not split into warring factions". He added "American
Medicine cannot afford a divided profession. Indeed, if we
divide, American Medicine will not survive as we know it today".

Dr. Davis also reported a very favorable response to the
challenge given in his Inaugural Address for physicians "to tithe
four hours a week to community service". He said he had received
many favorable communications from physicians, medical
organizations, and public groups, and stated "they tell me they

agree that physicians need to be more extensively perceived as
caring individuals who take a vital part in community life".

SPEAKER ON ANTI-TRUST

An address by Charles F. Rule, head of the Anti-Trust Division of
the U.S. Justice Department, Tuesday morning was an unexpected
and unwelcome addition to an already crowded program. He warned
the delegates that felony criminal charges will be leveled
against competing physicians if they fix fees, allocate patient
territories, or boycott insurers. He was at times pedantic, at
other times threatening, and appeared to be trying to intimidate
physicians into hiring lawyers to keep them out of trouble. The
address was so poorly delivered that many of us would have paid
little attention to it, except that the content was so offensive.
Just before the midday break, a delegate from Houston, Texas, was
recognized at microphone and gave a highly charged, emotional
speech, which I think reflected the opinions of many of the
delegates. He had gone to considerable trouble to get an early
copy of the speech, and read excerpts from it with appropriate
comments .

I had heard earlier that Mr. Rule was a self-invited guest, but
later we were told by Dr. James Sammons, AMA EVP, that he had
been invited to give this address because of problems that
physicians in several areas of the country had incurred with
alleged anti-trust violations, and in which the AMA had also been
involved. This was intended to be an "educational" address, but
it certainly was received as an attempt at intimidation.

At the midday break, I overheard a comment by Dr. Harry Schwartz
(Ph.D.) who is a well-recognized medical commentator for the New
York Times. Private Practice, and other publications, as well as
the author of a book entitled The Case for American Medicine.
Talking to Dr. George Alexander, the Houston Delegate, Schwartz
said "George, you are the hero of this Convention". And indeed
he was!

"MEDICALLY UNNECESSARY" STATEMENTS

The House commended the Board of Trustees for its activities on
this important issue, but took notice that it is not yet
completely resolved by adopting the following policies: (1) That
the American Medical Association continue to call for the repeal
of the "medically unnecessary" provisions of Section 9332 (c) of
the Omnibus Budget Reconciliation Act of 1986; and (2) That
until such time as repeal is achieved, the American Medical
Association urge the Health Care Financing Administration to
require that there be stated on the medically unnecessary notices
mailed by carriers (a) the basis for the denial; (b) the name,
position, and title of the person to be contacted regarding
questions about the review; and (c) the screening criteria or
parameter used in denying payment for the service.

PROFESSIONAL LIABILITY

The House received a report describing the work of AMA's Special
Task Force on Professional Liability and Insurance and also the
Advisory Panel on Professional Liability. A continuing study
relating to expert medical witnesses was described. The House
adopted policy calling on the AMA to establish a policy that each
physician should be able to maintain what he or she determines to
be an appropriate amount of liability insurance except where
otherwise required by state law; and to support the policy that
physicians not be required to divulge the exact amount of their
professional liability coverage as a condition of hospital
medical staff privileges but should be allowed to provide
verification that the minimum level of coverage required by the
medical staff bylaws is in effect.

SCMA RESOLUTION

As directed by the SCMA House of Delegates, our delegation
submitted one resolution (Number 70) in regard to Hospitalization
Review Requirements of Self-Insured Companies, pointing out that
these companies are not subject to satisfactory standards, and
that many of them have adopted review requirements that may be
inconsistent with good medical care. Our resolution asked the
AMA Board of Trustees to thoroughly investigate current
governmental and/or other controls over self-insured companies to
determine whether there is adequate uniformity of requirements
for initial and continued hospitalization review and report to
the House of Delegates on the feasibility of seeking such changes
which would enhance the accountability of self-insured companies
in the administration of their respective health insurance plans.
The Reference Committee made minor changes in the Resolved, which
included that the report back to the House be at the 1989 Interim
meeting rather than the Annual Meeting. The amended resolution
was adopted without dissent. Dr. Robert D. Burnett of Los Altos,
California, member of the Council on Medical Service, and its
former chairman, told me that he considered this the most
important resolution submitted to the House.

OTHER IMPORTANT ITEMS

Actions of the House in regard to many other issues have already
been reported in the AM News in the issues of December 16th and
December 23/30. You are encouraged to read these two issues
carefully.

COMPOSITION OF THE HOUSE

There were 423 delegates seated at this meeting, including one
new specialty society, The American Academy of Pain Medicine,
which was granted a voting delegate at this meeting. Two
applying societies, both in the same field, the American Society
for Surgery of the Hand (applying for the second time) and the
American Association for Hand Surgery, were turned down by the

House, upon recommendation from the Board. There are now 7 7
delegates representing national medical societies, contrasted
with 336 delegates representing state medical associations, and
10 Section and Service delegates.

The House considered 66 reports and 129 resolutions, a large
volume of business, but not unusually so for an Interim Meeting.
Of course the RBRVS, as discussed above, was of such importance
as to be very time consuming.

HOUSE TAKES SHORTCUT

In mid-morning on Wednesday, with tight plane schedules staring
them in the face, and with important commitments at home, the
delegates adopted a very unusual procedure, unprecedented in my
memory, to expedite the conclusion of scheduled business. After
only the first item of Reference Committee F had been
considered, and with two other committee reports to go, a motion
was made to put the entire remainder of the committee report on
the "Consent Calendar". This meant that for any item to be
debated, there would have to be a request to extract it from the
calendar. Otherwise the items were simply read by number, and
the recommendation of the Reference Committee voted upon. The
same procedure was utilized for the last two committee reports.
Only a few items were extracted, and debate was limited.

I personally think that allowing this tactic was a mistake.
Although all items of business had been debated in the Reference
Committees, and then brought back to the House in well-considered
written reports from the committees, there may have been some
items which needed to be "aired" on the floor, which were passed
over with such a hasty procedure. The most important items of
business (as judged by those assigning the material to the
committees) , had been discussed at length (and at times almost ad
nauseam) in the consideration of the earlier committee reports.
Despite a two-minute restriction on debate by any one person,
there had been a considerable waste of time. The House had been
embroiled in time-consuming hassles, points of order, and counted
votes, and of course additional time was taken for the speech by
Mr. Rule. I believe the House, under firm control by the
Speakers which might at times appear restrictive, must discipline
itself to more expeditious consideration of early items of
business, to pace itself, so as to reserve adequate time for
consideration of all of the items of business.

GUIDELINES FOR CAMPAIGN ACTIVITIES

At the Interim Meeting of 1987 the House adopted Resolution 61,
designed to reduce campaign expenditures, and among other things
restricting room size for campaign events. At Annual 88, this
proved to have a number of problems, including fire hazards,
overcrowding, etc. The A-88 reference committee recommended that
this problem be addressed by the Convention Committee on Rules
and Order of Business. I was asked to chair this committee. We

considered all of the problems in considerable detail, with
extensive input from both of the Speakers. We brought in
recommendations which were adopted by the House and which are
essentially as follows:

1. That no state, specialty society, or coalition have more
than two nights of hospitality, only one of which may be
held in a public function room.

2. That no candidate shall have more than two nights of
organized campaign activities (e.g. standing in a receiving
line or distributing campaign paraphernalia) , only one of
which may be held in a public function room.

3. That lavish and extravagant campaign events be eliminated.

4. That the state where the AMA meets should feel no obligation
to sponsor a "host state party" and that host states are
encouraged to make a charge to cover expenses for these non-
campaign social events.

SMOAK ELECTED AMPAC CHAIRMAN

We were all highly gratified that the AMPAC Board, at its meeting
on Friday, December 2nd, elected as its Chairman Randy Smoak, a
Past President of the SCMA and Chairman of the SOCPAC Board.
This is indeed a signal honor and a real accomplishment. We
congratulate Randy on his achievement and know that he will do a
splendid job during the coming year.

SCMA DELEGATION

The SCMA had a full delegation at the meeting, including Randy
Smoak, Don Kilgore and John Hawk, delegates; Gavin Appleby,
Charlie Duncan and Walt Roberts, alternate delegates; Tommy
Rowland, President; Dan Brake, President-Elect; Chris Hawk,

Chairman of the Board of Trustees; Carol Nichols, Secretary;
Roger Gaddy and Steve Hulecki, delegate and alternate delegate to
the Young Physicians Section. Bill Mahon and Barbara Whittaker
were present from the staff.

Also Bob Schwartz, Greenville, Young Physician delegate of the
American Academy of Physical Medicine and Rehabilitation Therapy,
attended some of our caucuses. Several students from both MUSC
and the University of South Carolina attended the medical

students section. Mark Newberry, Vice-President of Academic

Affairs at MUSC, was also with us for part of the meeting.

Again, your delegation thanks the members of the Association for
the privilege of representing you. We also invite you to meet
with us, and to attend all South Carolina and Southeastern

Delegation functions at any AMA Annual or Interim Meeting.

THE SCHA LOSS CONTROL PROGRAM:
REDUCTION IN LIABILITY EXPOSURES FOR
HOSPITALS AND PHYSICIANS*

CHERYL KOOB**

JANE BRYANT***

Americans have been characterized as willing
to sue anyone for any reason. Hospitals and physi-
cians share concern over the increasing number of
suits filed on health care related issues.

To reduce liability claims for hospitals and phy-
sicians, the South Carolina Hospital Association
(SCHA) developed the Loss Control Program in
1975. It is funded by the Joint Underwriting Asso-
ciation (JUA) and the Insurance Reserve Fund
(IRF) which currently insures 54 hospitals in the
state.

In 1988, a representative from the South Caro-
lina Medical Association was appointed to the
SCHA Loss Control Task Force to ensure that
physician perspectives are incorporated into the
Loss Control Program.

The initial concept of the program was to re-
duce liability exposures in member hospitals.
Over the years, hospitals have been surveyed an-
nually for risks of professional liability, premises
liability exposure, and clinical apparatus liability
exposure. The professional liability component is
performed by a registered nurse Risk Manage-
ment Consultant. The premises liability and
clinical apparatus components are performed by a
Clinical Engineer.

In the first 11 years of the program, a general
survey was conducted of the entire hospital. As
high risk areas, such as obstetrics, anesthesia, and
emergency room, resulted in a greater proportion
of malpractice claims, it was felt “focused” sur-
veys would be more beneficial in decreasing lia-
bility claims. Concentrating on areas where
medical care had the most potential for having
liability claims became the concept that is used at
the present time.

° From the McNeary Insurance Consulting Services, Inc.,
and the SCHA Loss Control Task Force.

° Consultant, McNeary Insurance Consulting Services, Inc.,
PO Box 220926, Charlotte, NC 28222.

° Chairperson, SCHA Loss Control Task Force, and Risk
Manager, Greenville Hospital System, 701 Grove Road,
Greenville, SC 29605-4295.

The professional liability component consists of
medical record reviews (to assess documentation
practices), review of policies and procedures, re-
view of the physician credentialling system, oc-
currence reporting system, and the quality assur-
ance and risk management programs. The prem-
ises liability component consists of a review of the
safety program, review of surveys performed by
other agencies and reports, review of the haz-
ardous materials program, review of the security
program, and a general survey of the physical
plant. The clinical apparatus component consists
of a review of all clinical apparatus in the area to
be surveyed, especially high risk equipment. Also,
each year the previous years’ recommendations
are monitored for progress.

The risk management consultants use state (i.e.,
DHEC) and national (i.e., Joint Commission,
ACOG, ACEP, ASA, OSH A, EPA, etc.) standards,
as well as sound risk management practices, as
criteria when surveying a hospital. A written re-
port with recommendations is provided each hos-
pital and distributed to appropriate personnel
after the annual survey. The risk management
consultants provide assistance, if requested by the
hospital, in correcting deficiencies. Hospitals are
requested to respond to the recommendations
made by the consultants within 30 days. Written
responses are returned to the consultants and fol-
low-up is performed if indicated.

Last year, the focus of the annual survey was
obstetrics. Recommendations were given to hospi-
tals across the state to bring them up to date with
state and national standards in this area. This year
emergency rooms were targeted because of the
high frequency of liability claims in this area.
Also, hazardous materials management programs
were reviewed because of risk management con-
cerns about hospital waste.

The most frequent recommendations in these
areas have been in regard to documentation prac-
tices in the emergency room and ways to improve
or enhance hazardous materials management pro-

January 1989

SCHA LOSS CONTROL PROGRAM

gram$ to comply with federal and state regula-
tions.

The risk management consultants and SCHA
continually update hospitals, through memoran-
dums, newsletters, and educational programs, on
risk management issues and how to reduce lia-
bility exposures for hospitals and their medical
staffs. SCMA and SCHA are in the process of
developing a joint educational program which
will address the Loss Control survey findings re-
lated to emergency rooms. Collaboration between
hospitals and physicians is essential in ensuring
that liability is reduced.

The Loss Control Program will continue in its
effort to reduce liability exposures thereby miti-
gating or reducing liability claims in the state of
South Carolina. As other areas become identified
as high risk, emphasis will be placed on control-
ling risk in those areas. The very essence of the
Loss Control Program is to assure that every pa-
tient who enters the health care system is provided
quality health care. As hospitals and physicians
identify their risks and implement practices
which reduce their liability, they can work to-
gether more effectively in ensuring that high
quality patient care is provided. □

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NEWSLETTER

JANUARY 1989

MEDICARE UPDATE

Blue Cross and Blue Shield of SC held a series of workshops in
December in order to explain the 1989 Medicare program. It was
explained at the workshops that you should write Professional
Reimbursement (BC/BS of SC, 1-20 and Alpine Road, Columbia, SC
29219) , if you wish to obtain a copy of the clinical laboratory
fee schedule. It was also pointed out that there was a December
Medicare Advisory planned which would explain the HCFA changes in
Holter monitoring billing made since the October Advisory.

A special five percent bonus will be reimbursed quarterly to
physicians who provide services in Classes I and II Health
Manpower Shortage Areas (HMSAs) . The correct HMSA code should be
included on each Medicare claim. BC/BS also instructs you to
record the code for Classes III and IV HMSAs.

The following counties are entirely HMSA and the correct HMSA
class is given after the county name. You should put the correct
HMSA code on your claim:

ALLENDALE 3

BARNWELL 3

CALHOUN 1

CLARENDON 2

DILLON 4

FAIRFIELD 3

HAMPTON 4

JASPER 4

LEE 3

MCCORMICK 3

MARLBORO 4

SALUDA 3

UNION 2

WILLIAMSBURG 2

Parts of the following counties are designated as a HMSA:

( ) ABBEVILLE

( ) BAMBERG

( ) BEAUFORT

( ) CHESTER

( ) CHESTERFIELD

( ) COLLETON

( ) GEORGETOWN

( ) HORRY

( ) KERSHAW

( ) MARION

( ) SUMTER

( ) DARLINGTON

( ) GREENWOOD
( ) LANCASTER
( ) LAURENS
( ) ORANGEBURG

If you practice in one of these counties. Blue Cross & Blue
Shield of SC will send you a map which shows which areas are
designated as a HMSA and the correct code to use for your claims.

If you practice in a "split" county, you need to identify on the
list each county where you practice and send it to: Attention:

Office of the Director, Medicare Service Center, Suite 1300,
Fontaine Business Center, 300 Arbor Lake Drive. Columbia, SC
29223 .

MEDICAID UPDATE

AIDS Waiver Program

As of August 1, 1988, the State Health & Human Services Finance
Commission initiated an AIDS Waiver Program approved by HCFA.
This waiver will provide home and community-based services to
eligible Medicaid recipients diagnosed with acquired immune
deficiency syndrome and AIDS related complex.

Services which are covered as part of the waiver include:
private duty nursing, day care services, personal care aide
services and home delivered meals consisting of modified and
therapeutic-diets. Services for counseling, foster care and
hospice are also covered, as are traditional Medicaid Services
(i.e., drugs, physicians, hospital).

Home and community-based services for recipients diagnosed with
AIDS will offer the individual and the SC Medicaid program
alternatives to institutional care.

South Carolina is one of five states in the country to receive
funding for the AIDS Waiver Program. Specific policy guidelines
are available from SCHHSFC.

Obstetric Care - Fee Updates

Effective January 1, 1989, fees for some charges of Obstetric
care increased. The reimbursement for those procedure codes
includes :

CPT Code

Fee Increase fas of 1/1/89)

59410-Vaginal Delivery
59400-Cesarean Section
59420-Antepartum care only
59430-Postpartum care only
S1500-Initial OB exam

Emergency Room Visit Updates

$100.00
$100.00
$ 7.00

$ 7.00

$ 50.00

Effective January 1, 1989, Medicaid will follow Medicare's
updated policy for use of the unusual or special services codes
listed in the "Special Services and Reports" section of the CPT-4
coding manual.

Providers should submit charges for their normal services under
the procedure code for the basic procedure performed, and if any

unusual service is performed, submit charges with one of the

special service procedure codes (99050 - 99065) .

In addition, non-hospital based physicians should begin using the
90500 - 90580 series of codes for ER visits, adding a 26 modifier

to the appropriate code. If the ER visit was after regular

office hours, the physician may also submit a charge for

procedure code 99064. This would be an additional charge to
cover the special service of going to the hospital after normal
working hours.

EXPANDED " PERSONAL CARE” PROGRAM

^Earlier this month the SCMA held a press conference to announce
implementation of our newly revised "Personal Care" program. By
now you should have received a mailing regarding the SCMA
Personal Care program designed to assist non-participating
physicians in better serving their Medicare patients. At the
direction of the SCMA House of Delegates in 1988, the program has
been revised to establish an eligibility certification protocol.
Under the expanded program, local aging service providers will
provide eligibility cards to qualifying Medicare patients (up to
150% of poverty - $8,250 for a one-person family or $11,100 for a
two-person family) to be presented to the "Personal Care"
physician. The physician retains the right to accept assignment
on an individual basis regardless of whether or not the patient
has been issued an eligibility card; however, the SCMA strongly
encourages "Personal Care" physicians to accept assignment on
these eligible patients.

We urge that you carefully study the information furnished in the
mailing. Non-participating physicians who did not enroll earlier
are encouraged to do so. Also, physicians who are changing their
par status to non-par this year should seriously consider
enrolling.

Ilf you have questions or need additional information, please call
Barbara Whittaker or Melanie McLendon at SCMA Headquarters.

PRO UPDATE
—

On December 1, HCFA contracted with Medical Review of North
Carolina (MRNC) for Medicare review in SC. Actual Medicare
review is expected to begin in February or March.

At the present time, MRNC is working with SCMA and all SC
specialty societies in reviewing proposed licensing criteria and
establishing a committee responsible for review in SC. MRNC has
hired Blake Williams, formerly employed by SCMA and BC/BS of SC,
to direct their review in SC.

Medical Review of NC, Inc., will conduct seminars for
physicians' office staffs (especially those responsible for
preadmission review) from 10:00 a.m. to noon as follows:

Wed. , Feb. 1
Thurs . , Feb . 2
Mon. , Feb. 6
Wed. , Feb. 8

Greenville Hilton, 1-385 at Heywood Rd.
Columbia Marriott
Holiday Inn at 1-95, Florence
Mills House, Charleston

Your office will receive a letter from MRNC regarding these
workshops. Workshops for hospital personnel will be conducted at
these same locations in the afternoon.

NEWS FROM THE STATE HOUSE

Following are new chairmen of committees of the South Carolina
House of Representatives: Donna Moss, Gaffney, - Medical

Affairs Committee, and Robert Brown, Florence - Labor, Commerce
& Industry Committee. Sarah Manly, Greenville, has been elected
to the House of Representatives to fill the unexpired term of
Chick Rice (deceased) .

Chairmen of Senate committees remain virtually unchanged for
1989.

DOCTOR OF THE DAY

Volunteers are still needed for the Doctor of the Day for the
1989 session of the SC General Assembly. If you can serve as
Doctor of the Day on a Tuesday, Wednesday or Thursday during
March, April or May, please call Jan Maynard at SCMA Headquarters
to schedule a date.

AIDS UPDATE

Additional Federal funding has been received by DHEC for the
Retrovir Program. However, the amount of funding was only enough
to allow DHEC to maintain its current case load plus add the
applications already on hand. Therefore, DHEC is unable to
accept any further applications. DHEC regrets this decision, but
continues to suggest that physicians refer appropriate
applicants to their local Department of Social Services for
coverage under the Medicaid Waiver Program.

OCCUPATIONAL EXPOSURE TO BLOOD-BORNE DISEASES

The Occupational Safety and Health Division of the SC Department
of Labor has issued an information memorandum, #88-x-77, which
addresses enforcement procedures for occupational exposure to
HBV, HIV and other blood-borne infectious agents in health care
facilities .

The memorandum provides procedures and guidelines to follow when
conducting inspections and issuing citations for health care
workers potentially exposed to these infectious agents. Also
included in the memorandum is the June 1988 update from the
Centers for Disease Control regarding universal precautions for
prevention of blood-borne pathogens in health-care settings and

checklist evaluations of employer training and education
programs .

For further information, call Melanie McLendon or Kim Fox at SCMA
Headquarters. To obtain a copy of the memorandum, contact the
Office of Public Information of the SC Department of Labor at
734-9612 or 734-9661.

RED CROSS TRANSPLANT PROGRAM

Since 1985, the Southeastern Transplantation Services Division of
the American Red Cross has been responsible for collecting human
tissue used in some 5,000 transplants. Although less known than
more publicized heart, lung and kidney transplants, bone grafts
are second only to blood as the most transplanted human tissue.
Nearly 200,000 patients require bone allografts each year in the
U.S.

Bone transplantation is used to treat victims of osteosarcoma,
scoliosis, disfiguring injuries, congential deformities and
orthodontic diseases. Bones and tissue can be donated by males
age 15-70 and females age 15-65, or on an individual basis for
other age groups.

Bones and tissue can be extracted from a donor whose heartbeat
and respiration have ceased, provided the surgery takes place
within 24 hours of death and the body is refrigerated. One donor
can benefit as many as 50 recipients.

To learn more about donation and transplantation, call the
American Red Cross at 1-800-922-5986 or 251-6153 (statewide),

1989 CPT— 4 CODE BOOK AVAILABLE

Remember to purchase your 1989 Physician's Current Procedural
Terminology (CPT-4) book. This book, revised and published on an
annual basis, is a listing of descriptive terms and identifying
codes for reporting medical services and procedures. Since
medical nomenclature and procedural coding is a dynamically
changing field, new procedures are developed and old procedures
become obsolete, it is a good idea to keep a current book on
hand.

To purchase your CPT-4 book, write to: Book and Pamphlet
Fulfillment: OP-341/8 , American Medical Association. PO Box
10946, Chicago, IL 60610-0946. VISA and MasterCard orders may
be placed by calling 1-800-621-8335. Copies are $25.60 for AMA
members and $32.00 for non-members.

AMA/GM EDUCATIONAL EFFORT: SAFETY BELTS

Available on loan from the SCMA Library is the latest
AMA/General Motors video project kit which is part of the
continuing educational project promoting wider use of safety

belts. The kit contains a two-part videocassette and a teacher's
guide. The two films on the videocassette were prepared for
young students of specific ages. "Safety Belts: For Dummies or
People" is designed for youngsters in the six-to-eight-year range
and encourages them to use seat belts. "The Game of Life" is
geared for students in junior high and demonstrates the effects
of alcohol consumption on driving abilities. To obtain the kit
on loan, contact Melanie McLendon or Kim Fox at SCMA.

AMA TELECONFERENCE VIDEOTAPES

The AMA announces the availability of two 90-minute videotapes
containing full proceedings of HSN teleconferences on "Beyond
Tort Reform: New Developments in Professional Liability" and
"Health Legislation 1988: Update and a Look Toward 1989." Copies
may be purchased for $7 5 each or you may request copies on loan
for a seven-day period for a $25 shipping and handling fee. To
place orders for either purchases or loan use, call Irene
Foster. AMA Division of Television. Radio and Film Services.
(312) 645-5102.

CONFERENCES TO BE HELD

The second annual Palmetto State Medical Student Conference will
be held January 20-21, 1989 in Charleston. Registration is
$15.00 per person. For further information, contact the MUSC
Student Activities Office at (803) 792-2693.

A Joint Commission on Accreditation of Healthcare Organizations
program to help hospitals with 1989 standards will be held
February 16-17 at the Radisson Hotel in Columbia. This pre-
survey tool will assist hospital personnel in interpreting and
applying standards in the 1989 edition of the Accreditation
Manual for Hospitals. For further information, contact Doris
Clevenger, SCHA. 796-3080.

CAPSULES

Vasa W. Cate, M. D. , has joined the staff of Blue Cross and Blue
Shield of South Carolina, Medicare Division, as part-time
medical director. Dr. Cate will continue with his private
practice in Lexington County.

Milton D. Sarlin, M. D. , was chosen the 1988 Medical Executive of
the Year by the Medical Group Management Association.

Anne-Marie C. Leventis, M. D. , Family Practice resident at the
Anderson Family Practice Center, is one of 25 residents in the
country to receive the AMA/Burroughs Wellcome Leadership Award.
She was cited for her volunteer work with a local "Doctors Ought
to Care" group to counsel schoolchildren to shun drugs and
alcohol and for assisting a teen pregnancy prevention council.

THE SOUTH CAROLINA DENTAL ASSOCIATION
AND THE S.C. MEDICAL MALPRACTICE JUA

JAMES H. GAINES, D.M.D.*

The Legislature passed enabling legislation to
allow the creation of the South Carolina Medical
Malpractice Joint Underwriting Association
(JUA) in 1975. At that time dentists in South
Carolina were not nearly as concerned about this
subject as were the physicians.

By and large, dentists had not then generally
been discovered as targets for significant malprac-
tice actions. As a result, we did not draw the
immediate concern of the insurance industry that
befell physicians and surgeons.

We are told that insurance companies back
then generally had us lumped under something
called “miscellaneous professional liability,”
wherein a number of so-called low risk professions
were put together for experience and rating pur-
poses. Apparently this had been customary for a
number of years. As a result, the insurance indus-
try really didn’t know what the specific dental risk
factors were, and consequently rates were low and
availability was no problem.

The American Dental Association (ADA) was
prophetically aware of the potentiality of coming
problems in the malpractice area. Nineteen years
ago they set a program of protection into motion
with CHUBB as the carrier, which became known
as the ADA Professional Protector Plan (P.P.P.).

This “package” policy combined all the areas of
coverage normally needed in a dental office so far
as property and liability protection was con-
cerned. It automatically included professional lia-
bility (as we preferred to call it) for at least
$1,000.00.

As a result of this foresight, S.C.D. A. co-endors-
ing The Professional Protector Plan provided our
members with the availability of a first-class oc-
currence professional liability policy at reasonable
rates.

By 1978, except for the Association Plan, The
South Carolina dental malpractice marketplace
had largely dried up. Out of concern for our

° 870 Cleveland St., No. 2-C, Greenville, SC 29601.

fellow dentists who were non-members and the
lack of a competitive market, we appealed to The
Insurance Commission that an emergency did, in
fact, exist. Subsequently members of the dental
profession became eligible for JUA coverage and
Dr. George P. Hoffman of Greenville became
dentistry’s first JUA Board Member.

Most dentists are members of The South Caro-
lina Dental Association. Since our sponsored cov-
erage stayed on an occurrence basis and the rates
remained reasonable, only a minimal number of
South Carolina dentists became insured with the
JUA. S.C.D. A. had a good program, well-admin-
istered, providing many needed facets of cover-
age, so there was no reason to leave it.

A few years ago storm clouds appeared and
matters began to worsen. The insurance carrier
(CHUBB) we had used for years decided for their
own reasons they no longer would provide cover-
age. A replacement carrier (CNA) was obtained
with all hopes that it would work out.

After several uncertain years, the shoe fell. The
new carrier unilaterally announced that coverage
would only be provided on a claims-made basis
and difficulties in continued negotiations as part-
ners were appearing. For these reasons and others,
the ADA withdrew endorsement leaving it to the
state associations to determine their best course of
action since the Professional Protector Plan
(P.P.P.) would still be marketed.

The South Carolina Dental Association con-
tinued to support the P.P.P. until the claims-made
policy form was effectively filed in South Caro-
lina. We then withdrew our endorsement.

We have always felt the occurrence form pro-
vides the greatest measure of protection for our
members for their premium dollar and commend
the JUA and PCF for remaining on that preferred
form over the years. With it there are no new
questions of coverage, additional premiums or
other contingencies down the road. Not so with
the claims-made policy.

The particular claims-made policy we were

January 1989

THE DENTAL ASSOCIATION AND THE JUA

offered was, perhaps, as good as any on the mar-
ket. There are, however, some built-in problems
peculiar to such coverage. Great care is required
at application time (annually) to adequately in-
form the would-be carrier of any possibility of any
known circumstances which may lead to claim.
Failure to adequately inform the carrier (to their
satisfaction) of any such happening would most
likely lead them to not providing coverage for a
claim which had its origins prior to the policy
date. With an occurrence policy there are no such
problems since the prior occurrence policy would
defend against the claim.

Here in South Carolina we dentists are fortu-
nate to have the availability of a reasonably priced
occurrence form professional liability insurance
policy through the JUA as an option in our insur-
ance planning. It is a privilege not universally
enjoyed.

LOSS PREVENTION

The old Professional Protector Plan provided
loss prevention seminars, workshops and publica-

tions. They worked with sponsoring state associa-
tions in these areas and through professional
assessment committees of those state associations.

The South Carolina Dental Association has an
on-going Dental Risk Management Committee.
We publish a Risk Management periodical (sim-
ilar to the one published for physicians by the
S.C.M.A.) and utilize programs prepared by the
American Dental Association, such as Risk Pre-
vention Manuals, a series of video tapes which are
regularly updated, and seminar-type programs
available to both local and state dental associa-
tions. The Oral Hygienists have developed on-
going programs for their specialty inasmuch as
their requirements differ from other dentists.

The JUA is now the principal provider of pro-
fessional liability insurance for South Carolina
dentists. We will work closely with the JUA in
helping to continue to experience a low level of
claims by providing a comprehensive dental risk
management program as is being done with the
South Carolina Medical Association and the South
Carolina Hospital Association. □

Cheiron is the practice management
system that combines the latest
advances in high technology with a commitment to
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We take pride in our ability to adapt
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Call for more information.

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The Journal of the South Carolina Medical Association

Now America’s
oldest professional

liability insurer
has come to
South Carolina.

With the current liability crisis
escalating, you need to take a
close look at your coverage and
the company that stands behind
it. Then take a close look at us.
You’ll see we carry the highest

Contact Stu Mitchelson today at
704/541-8020. He’s the oldest
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Stuart Mitchelson, P.O. Box 13489
Charlotte, North Carolina 28211, (704) 541-8020

MALPRACTICE PROPHYLAXIS

JOHN R. HUNT, M.D.*

“I still can’t believe that my long-time doctor
was sued for malpractice and the fact that he lost
is even harder to comprehend,” confided a mu-
tual patient and friend to me recently. As we
discussed our mutual acquaintance, my friend
was genuinely surprised to learn that nationwide,
malpractice suits are on the rise as seven out of ten
doctors have been or are being sued. While our
experience in South Carolina is somewhat better
than the national experience, malpractice actions
are affecting you or me or our dedicated, compe-
tent, devoted colleagues with striking regularity.
Certainly most physicians today realize the
litigious nature of the society in which we live and
practice and have altered habits or taken precau-
tions which they feel will be helpful in avoiding
the circumstances which might lead to a malprac-
tice suit. Yet it seems that the “Malpractice Crisis”
continues as some doctors aren’t able to either act
responsibly or fail to take adequate measures to
protect themselves. Interestingly enough, about
one-half of physicians sued have been the target of
a previous liability claim. Whereas nationally, 70
percent of all malpractice claims were felt to be
without merit and were closed without any pay-
ment, 30 percent of the cases were felt to have
grounds for suit. Could these cases be prevented
by “Malpractice Prophylaxis?” Obviously, there
are things that all doctors can and should do to
prevent an action from happening in the first
place. The purpose of this paper is to review seven
areas which are frequent liability pitfalls.

1. Communication: We must talk with our
patients and their families. We are criticized for
taking on too much work, for being on too many
committees, for seeing too many patients in too
little time. As the proverb recounts, “Pay me now
or pay me later,” we must give our patients
enough time now or risk the prospect of devoting
a tremendous amount of time and effort and
anxiety defending ourselves from a legal action. If
a physician has taken the time to talk and listen to
the patient and the family, he will almost never be

° 703 N. Fant St., Anderson, SC 29621.

sued, no matter what the outcome. He is thought
of almost as a member of the family.

Non-verbal communication is just as important
as what is said. We must learn to avoid the “Rolex
Bedside Manner.” Our patients need to see us as
one of them. They need to feel that we are the
“same kind of folks” as they are. If they feel that
we are talking down to them, they will resent it.
The resentment is just the fuel which is needed to
provoke some patients or families to seek legal
counsel if things don’t go as expected.

2. Referral of Hostile Patients: We must learn
to refer patients we don’t feel good about. Within
the first few minutes of interacting with a patient,
most of us have very definite feelings about
whether we like that individual and whether we
will get along well. This requires that both patient
and physician develop a trusting relationship with
each other. If the “vibrations ” which we get are
bad, we need to realize that the patient is probably
getting a bad feeling about us also. We need to
seriously consider referral of that case. We have
no obligation, except in an emergency situation, to
take a case about which we have uncomfortable
feelings. Besides the fact that most of us don’t
need additional patients, we certainly don’t need
the hostile patient who is likely to cause us much
grief down the road. Even though we are not
getting along with a given patient, we must realize
that the physician down the street may get along
famously with that individual. Rather than just
asking someone to “get out of my office,” it is
much more honest to sit down and explain to a
hostile patient that “we don’t communicate very
well, and I don’t think I can give you the kind of
service that I know you want and that your medi-
cal condition deserves. I’m going to refer you
somewhere else.”

Likewise, we should pay attention to our office
nurse or receptionist. If they have a real person-
ality conflict with a given patient if may be best to
refer that patient.

3. Informed Consent: We need “informed
consent” for anything we do that invades a pa-
tient’s body. We should be in line with what others

The Journal of the South Carolina Medical Association

MALPRACTICE PROPHYLAXIS

in our area in the same speciality are doing in
terms of written consents. However, for any invas-
ive procedure, we, the physicians, must explain
the situation such that an average “reasonable
man” will understand the options he has, the
probable outcomes and the potential complica-
tions of any given choice which he makes. He, the
patient, should make the choice to proceed with a
given treatment plan. Most attorneys presently
recommend that a formal consent be obtained for
anything that is not “routine.” An explanation
which has been suggested is that “the courts are
responsible for making us have to get this formal
consent.” Presently in South Carolina, it is not
clear just how far one should go in obtaining a
formal consent for any non-routine (IV’s, Subcla-
vian lines, Blood Transfusions, etc.) procedure.
Many physicians are concerned that too legalistic
an approach may sensitize patients legally and
make them more likely to think in terms of a legal
solution to any perceived problems.

Many questions exist about what constitutes
adequate informed consent. The patient and his
physician decide what is adequate informed con-
sent most of the time. When problems arise, how-
ever, the court decides. The court’s job is greatly
simplified if there is a document which spells out
the consent. How far we in South Carolina should
go in providing evidence of adequate informed
consent for a possible future court action is not
clear at present. Surgeons in Florida are presently
being advised to obtain videotaped consents or at
least audiotaped consents for most procedures. I
do not feel this is necessary in my practice at
present, and feel that in most cases it would be
detrimental to the relationship of trust which I
want to foster with my patients. In most cases, our
hospitals prescribe a standard consent, but this
does not relieve us individually of discussing pro-
cedures and treatment plans with patients. One
good suggestion is to draw the patient a picture on
the back of the consent form. This then becomes a
part of the permanent record.

4. Speak English, not Medical Jargon: Most
patients are afraid as they sit in our office and hear
us talk to them. If we use medical terms they will
not understand, they won’t say they don’t under-
stand then, but years later on the witness stand
they will relate that they did not understand. It is
our duty to take all of our medical jargon and
translate it into plain English. The average educa-

tional level of a patient, and a juror, in South
Carolina is approximately the eighth grade. Our
discussion should be in terms that the average
eighth grader can understand. At the same time
we should be very careful to avoid a condescend-
ing or “talking down” attitude.

5. Honesty is the Best Policy: If something bad
happens, admit it! Tell the patient and the family
the truth — exactly what happened and what you
are going to do about it. Spend some time commu-
ning with the family. Cry with the family or the
patient if that is appropriate. Go to the funeral. Go
to the home. Be involved just like a member of the
family. Even if the patient has suffered damage as
a result of something you have done, in 50% of the
cases, you will not be sued if you are totally up
front about what happened.

On the other hand, if you don’t talk with the
patient/family, if you ignore their anxiety about a
bad outcome, if you try to sweep it under the rug,
or try to fix the chart to show that you didn’t do
anything wrong, there is a high probability that
you will be sued.

6. Shoppers: One of the significant items of the
History of any new patient relates to the previous
physicians. If you get the impression that this
patient has left his prior physician under bad
circumstances, be careful. Call and discuss the
case with the prior physician. If this patient could
not get along with your colleague, chances are
that he will not be able to get along very well with
you.

Another item of the History which you need to
know and should not be afraid to ask about relates
to the medicolegal history. You have every right
to know if this patient has been a plaintiff in a
lawsuit before. You should not ask “Have you ever
sued a doctor before?” But rather ask whether this
patient has been involved in litigation so that you
might get a better idea of the total complex of the
medical history. If the patient does have a history
of litigation, and you don’t want to become in-
volved, you have every right to decline to accept
that patient.

7. Records: All attorneys agree that it is ex-
tremely detrimental to your case if you don’t have
legible office notes. In today’s environment, it is
much more preferable to have typed office notes.
With the availability of small portable pocket
dictating machines, there is very little reason for

January 1989

MALPRACTICE PROPHYLAXIS

handwritten office notes. One can generally di-
cate a better note more quickly than trying to
write it by hand. I believe that the office note can
usually be dictated in the presence of the patient.
If the patient has any disagreement with anything
that is said, he has an opportunity to say so. I also
suspect that patients feel better knowing what is
being said about them. A dictated note also pro-
vides an immediate report to send back to the
referring physician or other involved physicians
in appropriate cases.

AREAS OF FREQUENT
LIABILITY PITFALLS

1. Communication

2. Hostile Patients

3. Informed Consent

4. Medical Jargon

5. Ignoring/Denying Mistakes

6. Doctor Shoppers

7. Recordkeeping

Malpractice suits and “bad doctors” are not
synonymous. The incompetent physician exists,
but all major studies have found that these physi-
cians represent only a minor element in the over-
all picture of medical malpractice. Dedicated,
competent, well-trained South Carolina physi-
cians, who have lost rapport with their patients or
patients’ families, represent the bulk of our local
cases. Many of us can profit by using some of the
suggestions we have mentioned to prophylax our
own practice against the specter of a malpractice
suit. □

MALPRACTICE PROPHYLAXIS RESOURCES

1. Mr. Richard Jones, Malpractice Defense Attorney; Gaines-
ville, Fla.; Speech given, May, 1988 at the SCMA annual
meeting in Charleston, S. C. Tape available from SCMA.

2. Malpractice: A Guide to Avoidance and Treatment, by
Kenneth Brooten and Stuart Chapman. 1987. Grume.

3. Malpractice: A Guide to the Legal Rights of Doctors and
Patients, by Donald J. Flaster. 1983. Scribner.

4. Malpractice: A Trial Lawyer's Advice for Physicians, by
Walter G. Alton, Jr. 1977. Little.

5. Malpractice Depositions: Avoiding the Traps, by Ray-
mond M. Fish and Melvin E. Ehrhardt. 1987. Medical
Economics Books.

6. “Professional Liability in the 80s.” Chicago: American
Medical Association Special Task Force on Professional
Liability and Insurance, 1984.

7. “Response of the American Medical Association to the
Association of Trial Lawyers of America Statements Re-
garding the Professional Liability Crisis.” Chicago: Ameri-
can Medical Association, Special Task Force of Professional
Liability and Insurance, August, 1985.

The Journal of the South Carolina Medical Association

SO YOU ARE A DEFENDANT IN A
MALPRACTICE ACTION

DONALD V. RICHARDSON, ESQUIRE*

Like rain, there seems to be a time in a physi-
cian’s life when a medical malpractice action falls.
This article is about what you may expect from
your defense counsel in your defense.

As soon as you or your staff or family receive
the suit papers (Summons and Complaint) in-
stituting the action, you should note on the face of
the Complaint the date and time they were re-
ceived, and initial this notation. When the suit
papers are sent to your insurance carrier, be sure
that you also transmit everything you received. In
a death case, a case involving a child, or a married
couple, two separate suits are usually served at the
same time. In a death case, you will not be able to
tell the wrongful death action from the survival
action unless it states on the face of the Complaint
which action it is. If it does not so state, you can
only determine the difference by the civil action
number, which will be different on each Com-
plaint. In the case of a child, there will be an action
in the name of the parents and an action in the
name of the child. In the case of the married
couple, there will be an action in the name of the
husband and an action in the name of the wife.
Also, be sure that you were not served with Inter-
rogatories or Requests for Production. It is a good
practice to send everything you receive to your
insurance company. Accordingly, if you receive
anything other than the suit papers, you must also
notify your insurance company of this fact. The
additional documents should also be dated and
initialed.

Upon the assignment of the defense attorney to
represent your interests, a meeting should be es-
tablished with him as soon as possible. At the
meeting with the defense counsel, take all medical
records you have in your possession concerning
the patient. Be sure that your attorney has a
complete copy of the original records, and that
they are legible. If your attorney cannot read your

° Richardson, Plowden, Grier and Howser, 1600 Marion St.,
P.O. Drawer 7788, Columbia, SC 29202.

records, by all means have the records typed out in
legible form for his use. This initial meeting
should be for the purpose of introducing the medi-
cal records to your attorney, reviewing those rec-
ords with your attorney, and ascertaining what
course of action you are to follow in the defense of
the litigation.

It is imperative that medical research be con-
ducted as soon as possible. The defense attorney
and the physician should collaborate as to how this
medical research should be best accomplished.
The research will determine not only what your
best defense is, but will also assist you in preparing
for the attack that will surely be based upon the
medical literature. Your attorney should be given
copies of any literature search you perform. The
literature search can also be used in meeting with
treating physicians to refresh their memory on
current medical practices.

Your attorney will secure by Subpoena all other
medical records from treating physicians and hos-
pitals. These records are immediately available by
a Rule 45(b) Subpoena, which is simply prepared
by the attorney and served on the particular in-
stitution or physician. These records should be
obtained very quickly, and you should be fur-
nished with a copy for your immediate review.

After you have received all of the medical
records of the attending physicians and hospitals,
and have secured all of your office records, they
should be reviewed. After you have reviewed
these records, you and your defense attorney
should determine the proper course of action.
Hopefully, by the time you have reviewed the
records you will also have the current literature
and will be in a position to consider the services of
an expert witness.

At some point in time, you will be advised that
the Plaintiff’s attorney desires to take your deposi-
tion. Hopefully, your attorney has already taken
the depositions of the Plaintiffs and any other lay
witnesses who relate to the history of the patient
and to gather the facts and circumstances sur-

January 1989

A DEFENDANT IN A MALPRACTICE ACTION

rounding the alleged malpractice. It is imperative
that the Plaintiffs be deposed promptly in order
that' they cannot back-fill their history after your
deposition had been taken. If you admit during
your deposition that you would have done certain
things if the patient had given a particular history,
you can rest assured that this particular history
will be provided by the Plaintiffs if they are
deposed after you. Do not expect the truth as you
perceive it to be to come from the patient. It
would be startling if the patient admitted to the
history as you have noted it in your records.

Once you are notified that you are to be de-
posed, you should meet with your attorney, who
should explain to you the purpose of the deposi-
tion and the use of the deposition at trial by the
opposing counsel. You should be fully and com-
pletely prepared for your deposition, just as if you
were going to trial. You should understand the
records completely, including everything from
the nurse’s notes to the laboratory data. You
should never attempt to practice law, but should
practice medicine at the time of your deposition.
You should answer any questions fully and com-
pletely in a medical context. If you have an opin-
ion concerning causation or your treatment, do
not hesitate to give it. In short, when your deposi-
tion is taken, you should be the very best of friends
with your attorney. If your attorney does not give
you this service, you should demand it. In all
probability, your case will be won or lost at the
time your deposition is taken. It is rare that a
physician can overcome at the time of trial his
unpreparedness at his deposition.

Once your deposition is taken, you then serve as
a consultant for your attorney. You should know
what is going on in your litigation at all times. You
should help your attorney digest any medical
records that may be discovered, interpret any
medical literature that may be obtained, and assist
him in responding to new facts as revealed by the
attending physicians. Hopefully, by the time you
are deposed, your attorney has already started
discussing the medical records of the treating
physicians with you so that you may be fully
informed of the significance of these records and
the opinions contained therein.

When your attorney receives Interrogatories,
you should assist your attorney in drafting re-
sponses to them. A review by you of the answers
proposed by your attorney will be very helpful in
maintaining a good medical perspective. Please

take the time to read any of the attorney’s pro-
posed Answers to Interrogatories and help him
draft the correct medical response. At all times
you should strive to be medically correct in any
response that you give to the court.

You will not have a confrontation with oppos-
ing counsel again until the time of trial. Generally,
there are only two times the physician will be
directly confronted by opposing counsel in any
adversarial proceedings. The first is when your
deposition is taken by Plaintiff’s counsel, and the
second is when the case is tried in court.

If you learn that other attending physicians are
to be deposed by the Plaintiff ’s attorney, be sure to
discuss this with your attorney to be sure that he
has already discussed the case with the attending
physician and has ascertained what the attending
physician is going to testify to in advance. Every
now and then, an attending physician’s opinion
will not be medically correct. It is necessary to
secure the medical literature to educate that phy-
sician so that he is correct in his medical diagnosis
and the causation theories in this case.

You should always look at the damage aspect of
the case insofar as it is related to charges against
you. Do not hesitate to check the amount of the
hospital bills, bills from attending physicians, and
any loss of function or disabilities claimed by the
patient. For example, if a hospital bill is submit-
ted, how is that bill increased over the normal
amount for the original disease process? A physi-
cian is not responsible for the normal conse-
quences of the disease process. He is only responsi-
ble for that act of his which prolonged or in-
creased the expenses of the patient. If the patient
has lost her renal function, not through an act of
malpractice, but through a disease process, that is
material and should be exploited. Do not assume
that all damages or disabilities or permanent im-
pairments are a result of malpractice. The act of
malpractice must directly or proximately cause
the harm or the monetary loss to the patient. In
essence, did the act of malpractice alleged against
the physician cause the result, damage, or impair-
ment of the patient? If it is attributable to the
disease process, the physician is not responsible.

Defense is a team effort and as a key member of
this team, you should be aware of all the defense
efforts.

In summary, you should meet with your at-
torney as soon as the action is instituted and prior
to your deposition to be sure that he understands

The Journal of the South Carolina Medical Association

A DEFENDANT IN A MALPRACTICE ACTION

your medical position. You should assist your at-
torney in securing the medical records of any
hospital or attending physician and suggest cer-
tain records that may be beneficial to the defense.
If you do not know the answer, then secure the
records. You do not assume, you do not guess, you
must know the facts. Assist your attorney in the
medical research and explain to him the results of
that research. Your attorney can use the medical
research with the other attending physicians to
benefit your case and to fortify the opinions of
those attending physicians. Make every effort to
prevent an attending physician to testify in court
and have no opinion which may benefit you in the
defense of the case. Most attending physicians
would give an opinion as to the standard of care
and causation if they think that they are medically
accurate in doing so. Accordingly, it is the func-
tion of your attorney, with your assistance, to be
sure that the attending physician correctly knows
the medical standards and the appropriate medi-
cal treatment. This will eliminate off-the-cuff
opinions or prejudices, which could be very
damaging indeed. You must always watch for
biases that creep in among cross-specialties. A
specialist in infectious disease will immediately
think about infection and the appropriate treat-
ment to combat those infectious processes. How-
ever, a cardiologist will immediately choose to

rule out that the same patient has any inherent
heart disease. Each specialty carries its own bias.
You must be vigilant that a bias does not become a
standard for the non-specialist.

If the Plaintiff’s expert witness is deposed, most
defense counsels will offer you the opportunity to
be present at the time that deposition is taken. Do
not hesitate to afford yourself of this opportunity.
It will give you a first hand look at your adversary,
and you may be able to assist your attorney in
cross-examining the witness. If you have to travel
out-of-state to depose the Plaintiff’s expert wit-
ness, usually the carrier will pay your expenses in
making that trip. Your defense counsel will wel-
come your cooperation.

You will find that by working closely with your
defense counsel, you will become an aggressor in
the defense of the action. Once you have moved
from a Defendant to an aggressor, you have
picked the high ground and have taken the ini-
tiative away from the Plaintiff. You pick when the
case is to be tried if possible and be ready. An
aggressive defense is a very good offense and you
should be successful.

A team consisting of you, your insurance com-
pany and your defense attorney are the essential
elements of a good defense. Close and continuing
support by all members of a defense team are
necessary for a winnable case. □

January 1989

THE ARMY RESERVE
OFFERS NEW FINANCIAL
INCENTIVES FOR RESIDENTS.

If you are a resident in Anesthesiology
or Surgery*, the Army Reserve has a new
and exciting opportunity for you. The new
Specialized Training Assistance Program
will provide you with financial incentives
while you’re training in one of these
specialties.

Here’s how the program can work for
you. If you qualify, you may be selected to
participate in the Specialized Training
Program. You’ll serve in a local Army
Reserve medical unit with flexible schedu-
ling so it won’t interfere with your residency

training, and in addition to your regular
monthly Reserve pay, you’ll receive a
stipend of $678 a month.

You’ll also have the opportunity to
practice your specialty for two weeks a year
at one of the Army’s prestigious Medical
Centers.

Find out more about the Army
Reserve’s new Specialized Training
Assistance Program.

Call or write your US Army Medical
Department Reserve Personnel Counselor:

1835 ASSEMBLY STREET
ROOM 575

COLUMBIA, SC 29201-2430
(803) 765-5696 COLLECT

* General, Orthopaedic, Neuro, Colon/Rectal, Cardio/Thoracic,
Pediatric, Peripheral/Vascular, or Plastic Surgery.

ARMY RESERVE MEDICINE. BE ALL YOU CAN BE

THE DEPOSITION— THE DOCTOR, THE LAWYER

WILLIAM F. FAIREY, M.D., LL.B.*

The deposition is the single most significant
event which occurs in a malpractice suit. It is the
first salvo fired by the plaintiff. The deposition
sets the tenor for the entire case, it provides the
framework upon which future decisions are
made, e.g., the need for additional witnesses, the
tactics of the case, and ultimately provides the
basis for settlement versus trial. Although the de-
position occurs early in the proceedings, it is often
a "fait accompli," inasmuch as conclusions and
statements are often irretrievable and may not be
altered without damage to the credibility of the
witness.

It is more important to be thoroughly prepared
to give a deposition than to give testimony in an
actual trial because the deposition is the "condi-
tion precedent” upon which the trial testimony is
based; such testimony is substantially and at times
exclusively dependent upon the deposition. The
comprehensive preparation is vital whether we
are the defendant or whether we are a fact or
expert witness for the defendant. If we, as physi-
cians, want to help resolve the malpractice crisis,
we may not be in a position to cast a vote for tort
reform, but we can. as a witness to the facts or as
an "expert” witness, be maximally prepared to
offer medical information in a meaningful, direct
and succinct manner to support the defendant s
position.

For example, in a recent malpractice death
case, the defendants from a smaller South Caro-
lina community sought a pre-deposition evalua-
tion from specialists, to whom the defendants
often refer their patients; however, two separate
groups of South Carolina specialists, after only a
cursory review, dismissed the facts as incontrover-
tible from the plaintiff’s perspective and refused
to become involved. One specialist spent more
time calculating the damages on behalf of the
plaintiff, based on his medical prognosis, than he
did in evaluating the case. The defendants ulti-
mately obtained an out-of-state specialist who
studied the case carefully and testified as the

° P O Box 118, Pawleys Island, SC 29585.

defendants expert. The jury returned a verdict
for the defendants after only one hour of delibera-
tion! Undoubtedly, had the South Carolina spe-
cialists cared enough to give a more incisive
evaluation of the case, they would have reached
the same conclusion as the out-of-state specialist.

There seems to be a lingering "ivy tower” ver-
sus "LMD snob mentality that still prevails in
South Carolina. Whether or not there was some
basis for this attitude in the past is unknown, but
certainly it should not exist today. The smaller
communities are filled with excellent "LMD's”
who are bright, well-trained and who have earned
the respect due them from their medical col-
leagues who may only incidentally practice in the
larger cities. South Carolina physicians can and
should be a close knit medical community, show-
ing mutual respect and exchanging relevant med-
ical information. As a part of this mutual
exchange, constructive peer review at the local
and state level can be more easily attained. Tough
peer review is an essential ingredient of our medi-
cal legal endeavors.

And if we are to be effective participants, we
must know all the facts in the case, not just the
ones that may apply to our narrow area of interest.
We interpret our data as it relates to the other facts
in this case, and consult with the experts in the
field. As a bonus, this study usually extends our
own medical knowledge, and it definitely helps to
determine the direction and often the outcome of
a case.

In my own experience, I have not always been
so diligent. However, after several depositions as
an “incidental” witness in which I was only casu-
ally prepared, I suffered some embarrassment, a
sense of professional incompetence and most im-
portantly, made no contribution to the defen-
dant’s cause. I learned as a matter of survival to be
thoroughly prepared. I no longer underestimate
the examining lawyer’s ability to become thor-
oughly familiar with the medical issues and to
develop direct insight into the character of the
most complicated cases. The good attorneys ask
the tough questions and relevant followup ques-
tions when the answers are imprecise or inaccu-

January 1989

THE DEPOSITION

rate. Depositions for the physicians can be just as
grueling and threatening as oral examinations or
cross-examinations in the actual trial of a case.

Prior to the deposition, the physician must
know his case thoroughly and he must be able to
recite times, dates, medications, and what his
progress notes and the nurses’ notes state, all in the
context of the case. In a malpractice death case, a
few days before trial, as I was trying to develop
more information for my own testimony as a fact
witness, and as I was discussing the case with the
defendant physician, it became apparent that he
was not at all familiar with his own case, and this
was only a few days before actual trial! He was a
busy active physician and his lawyer was similarly
taxed for time; however, each was doing a disser-
vice to their case and to the system, medically and
legally, by their incomplete preparation.

The defense attorneys tell us that, as a defen-
dant physician, we may have to spend as much as
25 percent of our time with our attorneys for the
preparation of our cases, and for various hearings
and the trial itself, exclusive of the blood, sweat
and tears. Much of the time is spent in preparation
for the deposition. The interview with our attor-
neys, and the deposition itself are not squeezed
into the attorney’s or our schedule, but are care-
fully selected at a time which best suits our tem-
perament and after we have carefully studied our
case. We schedule the deposition at the place in
which we are most comfortable and the setting
that is most advantageous to us. It is vital that the
defendant physician attend all depositions so that
he might correlate the medical information for his
attorney, and to prompt him to ask the relevant
questions contemporaneously with the opposing
witnesses’ statements. The mere presence of the
defendant at the deposition of the medical expert
for the plaintiff tends to neutralize and restrain
this expert in his testimony. We are advised that
the attention to these details can make the dif-
ference in winning or losing the lawsuit.

Recently a group of defense attorneys com-
plained that their doctors are not properly pre-
pared for depositions, and some of the physicians
state that their lawyers do not properly prepare
them. A defendant physician reports that his at-
torney prepared him for his deposition by meet-
ing him at the local bar! After several drinks, the
defendant attorney, with strained sophistication
and apparent deep satisfaction, advised his client
to “tell the truth.” With that profound advice, the

interview was terminated, the physician client
dismissed, and the attorney turned to the more
serious business at hand. Certainly an extreme
example, but it represents an attitude that must be
avoided.

So, at times, there is a real communication gap
between the lawyer and the doctor in preparing
for the deposition. The ultimate direction and
responsibility must be that of the lawyer; how-
ever, if we, as physicians, are not fully and prop-
erly prepared, we must advise our lawyers of this
deficiency. A full discussion must ultimately take
place between the defense attorney and each of
the physicians testifying for the defendant. The
ideal setting is that all physicians meet together
with the attorneys so that each might better evalu-
ate his deposition or testimony in the context of
the entire case and more especially to educate the
attorneys.

There is an inherent gap between law and
medicine so that the lawyer believes he under-
stands the language, but often does not fully ap-
preciate the medical impact in the context of this
particular patient. This very situation occurred in
a suit in which the jury returned a verdict for the
plaintiffs in the high six figures. In a post-trial
interview requested by the physicians with the
defense attorney, it was apparent that the at-
torney, even at this late date, did not fully com-
prehend the medical implications, which were
readily available to him had there been more
thorough communication between the attorney
and the physician specialist who was providing
background information.

We are encouraged to hold post-trial and post-
deposition interviews for a constructive critique
of the case. More especially post-deposition cri-
tiques should be had with a sensitive evaluation of
the physician’s attitude, verbal content and ap-
pearance. The physician should be open to this
constructive criticism in order to be more effec-
tive and precise. It has even been recommended
that the physician be videotaped as he is “cross-
examined” by his attorney in a simulated setting,
so that he might be better prepared for the reality
of his deposition.

From my experience as a witness, I have come
to the realization that as physicians, we have med-
ical power, so let’s learn to use it in depositions and
in the courtroom. Let’s not be defensive and in-
timidated by the system. As witnesses, because of
our medical training, experience, and our hands-

The journal of the South Carolina Medical Association

THE DEPOSITION

on treatment of the patient in the given case, we
have the ability to know more about the case,
about the facts and their impact on the patient
than anyone else in the court system. This es-
pecially includes the cross-examining attorney
who should not be able to shake our testimony,
once we have, with reasonable medical certainty,
arrived at our own medical decisions. We need to
be precise, definite in our statements and opin-
ions, to identify the limitations of our testimony
and to draw firm and confident conclusions. Al-
though there may be other alternatives available
to the physician in the case, if we believe he has
taken the appropriate actions, then we state “in
my opinion, in this case,” this is my firm convic-
tion and approval of the treatment rendered.
There is a method to be learned and an attitude to
be developed through which physicians can make
a significant contribution.

As a profession, we are further challenged when
there is an attempt to hold physicians liable for
that nebulous, unpredictable element of medicine
for which there is no final, scientific answer. It is
these “bad outcome” cases especially that through
preparation and knowledge, we, as a medical
team, can inform the court of the unfairness and
inappropriateness of this kind of legal action.

There is some paranoia in every profession, but
what we as physicians are experiencing is not
paranoia, because “they” really are out to get us,
not because of who we are or what we do, but
because we are uniquely vulnerable to the tort
system due to the fact that medicine is practiced
as an art, but perceived by the public/ jury as a
science. Under our court system we are chal-
lenged to give precise, definitive answers for
which we are not trained nor is it our practice in
medicine to do, and which we, as physicians,
deem to be inappropriate. In spite of these obsta-
cles, we are learning as witnesses to make the
transition from the subjective medical mode to the
more objective, legalistic attitude that is required,
and that we now recognize as an opportunity for
medicine to provide.

As physicians, we are developing an insight into
the mechanics of malpractice suits and a better
understanding of our role in the courtroom set-
ting. Physicians’ involvement is one of the keys to
resolving the medical-legal dilemma occurring
regularly in our court system. We are needed —
let’s step forward to be heard in the given case and
to take part in our unique Risk Management
Program! And it all begins with the deposition. □

January 1989

QUALITY ASSURANCE, QUALITY MANAGEMENT, RISK
MANAGEMENT, AND OTHER BUZZ WORDS OF THE EIGHTIES
HOW DO WE USE THEM?

In 1955, when I graduated from medical
school, all that a new doctor had to do was pass the
State Board examination and he could go to most
communities and do whatever kind of medical or
surgical procedures he felt qualified to do. A
practice was then built on the word of mouth of
his patients and the sweat of his brow. His peers
seldom questioned or challenged his qualifica-
tions or ability, and the risk of being sued was very
small.

Time has changed that scenario, and we now
practice in a milieu that includes ongoing cer-
tification of hospitals, nursing homes and other
institutions, based mostly on evaluation of the
quality of care rendered. The doctor himself must
prove he has been properly trained and there are
boards certifying all specialties and sub-spe-
cialties. During the past 15 years, entry of third
parties such as the federal and state governments,
insurance companies, employers, citizens’ groups
and licensing boards into the medical care equa-
tion has clearly established the need, desirability,
and necessity of developing systems that evaluate
the quality of what the whole medical care deliv-
ery system does, and applying the knowledge
gained to the improvement of patient care, the
outcomes of care and the granting of privileges or
license to deliver that care.

Efforts to evaluate the performance of the de-
livery system and the ability to deliver high qual-
ity care go back to the early years of this century
when medical education was changed by the af-
termath of the Flexner Report. Then doctors per-
ceived the need to credential themselves accord-
ing to their training and skills. Since the early
seventies an urgency has been pushed by the
effects of federal legislation, the growing concern
for the value received for its dollars by third party
payors, the increasing need to manage the legal
risks, and the explosion of high tech medical pro-

cedures to find ways of identifying and evaluating
our problems. This has led to the development of
ways of managing these problems to the improve-
ment of a system bulging at all its seams with new
activities and technologies.

All these functions are now grouped together
and termed “Quality Assurance”; and most medi-
cal institutions have a Quality Assurance Commit-
tee, council, etc. We have begun to amass a great
quantity of data. Every medical institution and
every doctor in the state will need to begin to
evaluate procedures and outcomes, acquiring a
data base which must be studied regularly for the
identification of patterns which need to be ad-
dressed or modified, and thereby establish an
ongoing program of improvement in patient care.

Credentialing for privileges in institutions is
usually granted by proof of proper training and
demonstration of ongoing retention of skills and
knowledge in specific areas. The use of the quality
assurance data base to evaluate skills and knowl-
edge on a year to year basis will enable most
institutions to assure its consumers and pay
sources of continuing quality. This data base
should also inform each individual doctor of
where his educational needs lie and help him to
direct his educational endeavors in the right
direction.

I also envision an extension of this kind of
continuing evaluation data base for use in licens-
ing and board re-certification. We all bear the risk
together, so it behooves us to continue to develop
high grade, accurate, unbiased systems of quality
evaluation in order to meet the challenge of the
future.

R. L. Skinner, Jr., M.D.

305 E. Cheves St.

Florence, S. C. 29503

The Journal of the South Carolina Medical Association

RISK MANAGEMENT

The cornerstone and the most important factor
in preventing medical liability suits is the avoid-
ance of risks which lead to these occurrences. We
speak of this as risk management or risk preven-
tion. There are, of course, some risks which cannot
be prevented. There will be bad results from
injury, surgery, and disease which are beyond the
control of any physician. Some of these will be
blamed on the treating physician, and jury or
judges awards have been made in such cases when
the events were totally unpreventable. However,
there are things we can do even in these instances
to avoid suits, by establishing good rapport with
the patients and their families, showing concern
and willingness and openness to discuss what has
happened.

As we reach this point in our efforts to improve
the liability situation, we need to review and re-
emphasize some basic tenets which have been
stated in various ways in the Medical Liability
Bulletin.

Do we always take the time to discuss problems
with our patients and their families? Do we ex-
plain— in terms they can understand — the diag-
nosis, the treatment and, yes the alternative
methods of treatment in some instances? Do we
answer the questions of our patients and their
families clearly and fully? Do we speak with a
kind voice and in a sympathetic and understand-
ing manner? Are we available at times that may
not always be convenient to us, but may provide
an opportunity for families we could not arrange
to see during office or hospital runs? Do we in-
struct our office staff to show proper courtesy and
make every effort to see that our patients are
treated kindly and with understanding in all rela-
tionships including the financial ones?

Are our relations with our colleagues friendly
and cordial? Do we make off-the-cuff remarks or

unkind judgments? Are we brave enough to let a
friend know when and if he or she has a problem
and be willing to help0 Are we strong enough to
accept criticism ourselves and proper comments?
And are we broad-minded enough to see both
sides of all issues and involvements including pro-
fessional liability problems0

Six tips were stated concisely in one issue of the
bulletin and these are as follows:

1. Take a hard look at yourself and your practice.

2. Develop a rapport with your patients.

3. Communicate with your patients.

4. Provide thorough training and supervision for
your support personnel.

5. Adopt common sense billing procedures.

6. Keep medical records that are complete, cur-
rent, accurate and professional, unaltered and
legible.

Risk management requires repeated repetition
of these fundamentals. The South Carolina Medi-
cal Association/Joint Underwriting Association
Risk Management Committee plans to do just
that.

In our efforts to bring about meaningful
changes in our professional liability situation, let
us be sure that we all do our part in our personal
and professional behavior to enhance the true
respect for the humility and the integrity of our
profession and continue to eliminate the negative
factors and build on the positive ones.

Euta M. Colvin, M.D.

Department of Surgery
Spartanburg Regional Medical Center
101 E. Wood Street
Spartanburg, SC 29303

January 1989

LETTER TO THE EDITOR

ON THE COVER: A PROPER BALANCE

To the Editor:

For: The Physicians of South Carolina:

In the recent general election, the voters of
South Carolina overwhelmingly voted “Yes” on
Constitutional Amendment One. Through the
creation of the state grand jury, this will provide a
major tool in the battle against illegal drug
trafficking.

This victory was attributable in part to the
strong individual support of many of the members
of the South Carolina Medical Association. I am
grateful to the physicians of South Carolina for
their interest and support of this Amendment.

Sincerely yours,

T. Travis Medlock
Attorney General
The State of South Carolina
Columbia, S.C. 29211

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George Herbert 1593-1633

This month’s cover picture was made in the J.
Hampton Hoch Museum of Pharmacy, Medical
University of South Carolina. It is an attempt to
symbolize not only the dichotomy existing be-
tween the medical and legal professions but also
the need for a proper balance of the goals, ideals,
and philosophies of each if the public good is to be
served.

Betty Newsom

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The Journal of the South Carolina Medical Association

SOUTH CAROLINA MEDICAL ASSOCIATION

AUXILIARY

AMA AUXILIARY LEADERSHIP CONFLUENCE I

Seven South Carolinians were in attendance at the AMA Leadership Confluence I held October 9-11,
1988, at the Drake Hotel, Chicago, Illinois: Sheila Davis (Sumter), AMAA By-laws Chairman; Mary James
(Union), SCMAA President; and five county presidents-elect, Jeanie Stoddard (Greenville); Tina McLeod
(Spartanburg); Joni Kroll (Lexington): Kristen Palles (Florence); and Rosemary Suggs (Marion).

The purpose of the Confluence is to provide leadership training, and to assist local auxiliaries in planning
service projects that will meet the changing needs of the community. The program format consisted of
consultations and training sessions led by experts in their fields. We felt very fortunate to be given the
opportunity to participate in round table discussions on vital issues and concerns.

Topics covered during the sessions included membership, legislation, AIDS, adolescent health, teen
suicide prevention, parliamentary procedure, the nursing shortage, motivation and leadership, effective
programming, networking, and team efforts with our medical societies.

Sunday night’s keynote speaker was the interesting and humorous James E. Davis, M.D., President of
the AMA. After hearing from Dr. Davis and Mary Strauss, President of the AMA Auxiliary, we were in for
a special treat. The 4077th T.R. A.S.H., representing a medical auxiliary from South Dakota, delighted us
with their musical antics. After the entertainment, we went on a state exhibit walk which provided us with
program and project ideas.

We came away from Leadership Confluence with a wealth of information, inspired to share with our
peers what we had learned.

Tina McLeod, Pres. Elect
Spartanburg

Joni Kroll, Pres. Elect
Lexington

Rosemary Suggs, Pres. Elect
Marion

January 1989

INFORMATION FOR AUTHORS

We encourage original articles and letters to the
editor of potential benefit and interest to the
members of the South Carolina Medical Associa-
tion.

CORRESPONDENCE: All manuscripts and cor-
respondence should be addressed:

The Editor

JOURNAL OF THE SOUTH CAROLINA
MEDICAL ASSOCIATION
Post Office Box 11188
Columbia, S. C. 29211.

COPYRIGHT: All manuscripts should be accom-
panied by a transmittal letter to the editor, which
should contain the following paragraph:

“This original work has not been submitted
or published elsewhere, in entirety or in part.
I (we) hereby transfer, assign, or otherwise
convey all copyright ownership to the South
Carolina Medical Association in the event
that this work is published by the SCMA.
The above takes into account The Copyright Re-
vision Act of 1976, effective January 1, 1978. We
request authors to advise the editor of any prior or
anticipated duplication of their work in other
publications. Submission of material as a “com-
panion article” to material submitted elsewhere is
discouraged.

PRIORITY FOR PUBLICATION: The Journal
was founded in 1905 especially as a place for
practicing physicians to publish their original ob-
servations. This purpose continues to receive pri-
ority. Growth of institutions, especially of medical
school faculties, during this century may be, at
least in part, responsible for a decreased tendency
for practicing physicians to attempt scholarly
work. Concerned about this trend, The Journal
encourages practicing physicians to report origi-
nal observations, including series of cases or indi-
vidual case reports.

The Journal also welcomes timely review arti-
cles by institution-based physicians. However, it is
the philosophy of the Editorial Board that state
medical journals do not represent an appropriate
forum for research findings of a specialized
nature. Such findings, it is felt, belong in national
or regional specialty or subspecialty journals. Arti-
cles by institution-based physicians should serve

the information needs of a general physician
readership.

Articles dealing with social, economic, and eth-
ical issues are strongly encouraged. Historical or
philosophical essays are also welcomed, although
these are given lower priority compared to the
above categories.

TYPES OF ARTICLES
ESPECIALLY WELCOMED
FOR CONSIDERATION

1. Original scientific observations
( including case reports) made by
practicing physicians.

2. Concise, timely review articles (see
“Priority for Publication”).

3. Articles pertaining to current so-
cial, economic, and/or ethical is-
sues affecting the practice of
medicine.

4. Information uniquely pertinent to
the health care of South Carolin-
ians.

REVIEWING AND RESPONSIBILITY TO
READERSHIP: We will make every effort to
review manuscripts promptly. All manuscripts
will be reviewed by our editorial office, and when
indicated the opinions of outside consultants will
be solicited.

We welcome criticisms of journal content by
members of the South Carolina Medical Associa-
tion.

REPRINTS: These will be made available by the
publisher at established rates, at the time of mail-
ing of galley proofs.

LENGTH OF ARTICLES: We prefer concise
articles of approximately 2,500 words (approx-
imately eight typewritten pages, double-spaced),
with no more than ten references.

We regret that space considerations limit our
ability to publish longer articles, and request that
authors adhere to the above guidelines. Similarly,
tables and illustrations (see below), should be kept
to a minimum, and be specific and pertinent.

The Journal of the South Carolina Medical Association

Authors desiring to make additional data or
additional references available to readers are en-
couraged to do so by adding footnotes to the effect
that "additional references (or tables derived
from this data base, etc.) are available from the
author(s) upon request.’

MANUSCRIPTS: These should be typewritten,
double-spaced, and on one side of the paper. The
original and one copy should be submitted. The
title page should indicate the title, author(s), au-
thor’s address, and academic appointments, if
any. We request that the author’s name not ap-
pear on subsequent pages, to permit "blind” re-
view of the article, when desired. Authors should
retain one copy for use in proofing. Written corre-
spondence concerning proposed (potential) man-
uscripts is welcomed.

ILLUSTRATIONS: These should be submitted as
glossy, black-and-white prints no larger than a
standard page; smaller prints are desired. Or-
dinarily, publication of four small illustrations or
tables, or the equivalent, will be paid for by The
Journal. Any number beyond this must be paid
for by the author except under unusual condi-
tions. Illustrations should not be mounted, stapled,
or clipped. On the back side of each illustration,
the article title, figure number, and top of figure
(but not the author) should be noted lightly in
pencil. Legends for illustrations should be typed
on a separate sheet of paper.

REFERENCES: These should be cited con-
secutively in the text, in superscript, e.g., "Botts-
ford, et al ,3 ...” We recommend no more than ten
references, selected from more recent publica-
tions in accessible journals in most instances. Stan-
dard journal abbreviations should be used, with
the style for journal articles being as follows:

3 Bottsford JE, Bearden RC, Bottsford JG: A
ten year community hospital experience
with abdominal aorta aneurysms. JSC Med
Assoc 79: 57-62, 1983.

MATERIAL FOR COVER: The illustrations for
the cover of The Journal are selected by a mem-
ber of the Editorial Board, Thomas M. Leland,
M.D., 206 Baker Medical Circle, Charleston, SC
29405. Dr. Leland welcomes illustrations and sug-
gestions for the cover, including appropriate com-
mentary. Such suggestions should be sent to him in
writing at the above address.

ROE FOUNDATION AWARDS

Through a gift by the Roe Founda-
tion, a Thomas A. Roe and Shirley W.
Roe award of $3,000 is given each
year at the annual meeting since 1985.
All manuscripts submitted by South
Carolina physicians will be considered
for the award. The award is made, on
alternate years, to a practicing physi-
cian or to an institution-based physi-
cian, and is based on articles published
in The Journal during the two pre-
vious years.

Articles written by practicing phy-
sicians are judged by members of the
Editorial Board of The Journal on the
basis of original scientific content and
clarity of presentation. Practicing
physicians are encouraged to report
observations in The Journal, which
was originally established for this
purpose.

Articles written by institution-
based physicians are judged by out-
side referees, to be selected by the
Editorial Board. The current editorial
policy of The Journal is that original
scientific observations made by physi-
cians such as medical school faculty
members should, ordinarily, be sub-
mitted to peer-reviewed specialty
journals rather than to the state medi-
cal journal. Therefore, the Thomas A.
Roe and Shirley W. Roe award will be
based on review articles by institu-
tion-based physicians. Referees will
be instructed to base their selection on
(1) the quality of the review article,
and specifically its instructional value
for a general physician readership,
and (2) the significance of the author’s
contributions to his or her field. In-
stitution-based physicians should sub-
mit a current curriculum vitae and
reprints of articles representative of
their work, as published in specialty
publications.

January 1989

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The Journal of the South Carolina Medical Association

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION
VOLUME 85 FEBRUARY 1 989 NUMBER 2

GAMETE INTRAFALLOPIAN TRANSFER (GIFT):
THE SOUTH CAROLINA EXPERIENCE*

GARY HOLTZ, M.D.

GRANT W. PATTON, JR., M.D.

In vitro fertilization (IVF) has achieved wide-
spread clinical usage in the management of infer-
tility. However, clinical pregnancy rates are
seldom as high as 20%. 1 In 1984, Asch, et al.2
described an alternative technique allowing “in
vivo ” fertilization after the transfer of oocytes and
prepared sperm to the fallopian tube. This tech-
nique, gamete intrafallopian transfer (GIFT), is
now being widely utilized whenever possible due
to its superior clinical pregnancy rate. This report
describes the preliminary experience with this
technique in South Carolina.

MATERIALS AND METHODS

Twenty-four patients with mild endometriosis,
unexplained infertility, male factor infertility,
cervical factor infertility, or male autoimmunity
underwent 27 completed cycles of GIFT. All pa-
tients had previously undergone a thorough his-
tory and physical examination, semen analysis,
post-coital test, hysterosalpingogram, sperm anti-
body screening, confirmation of normal luteal
phase function, and laparoscopy. If the male had
not previously fathered a pregnancy, a hamster
egg penetration test was also performed. Most
couples with unexplained infertility had also re-
ceived a wide range of empiric treatment includ-
ing usage of human menopausal gonadotrophins

0 From the Southeastern Fertility Center, 900 Bowman Road,
Mt. Pleasant, SC 29464.

(HMG). Women with endometriosis had pre-
viously undergone surgical and/or medical man-
agement. Patients with male factor infertility had
been evaluated and treated as indicated by a
urologist, and all couples suffering from this had
undergone repeated cycles of intrauterine insem-
ination. Patients with sperm antibodies had been
treated unsuccessfully with corticosteroids.

Ovarian hyperstimulation was routinely ob-
tained with the use of HMG; two ampules of
Pergonal and two ampules of Metrodin on days
three and four, and thereafter two ampules of
Pergonal per day. Response was monitored with
daily plasma estradiol determinations and ultra-
sound scans of the pelvis from day seven onward.
Biologic response was also evaluated by assessing
the cervical mucus and vaginal cytology. When
the ovarian follicles were of the appropriate size,
10,000 units of human chorionic gonadotrophin
(HCG) was given 34.5 hours before the ovum
retrieval. The cycle was aborted if the estradiol
level fell by more than 30% the day after HCG
administration.

Husbands provided sperm samples obtained by
masturbation one and one-half to two hours be-
fore ovum retrieval. In a single case, both frozen
donor sperm and husband’s specimen were uti-
lized. Routine sperm preparation techniques were
utilized and the concentration of the sperm sus-
pension was then adjusted as required.

February 1989

GAMETE INTRAFALLOPIAN TRANSFER

Oocyte aspiration was performed during a
laparoscopic procedure by a technique similar to
that previously used for IVF. Patients were
prepped and draped prior to the administration of
either a general or epidural anesthetic. Pneu-
moperitoneum was established and maintained
with carbon dioxide. Three or four punctures
were routinely utilized to facilitate ovum retrieval
and tubal cannulation. After ovum retrieval, the
pelvis was irrigated and aspirated to remove all
accumulated blood and peritoneal fluid.

Aspirated follicular fluid and washes of each
follicle were passed to the laboratory for identifi-
cation of oocytes. The degree of maturity was
established for each egg and only mature or inter-
mediate ova were utilized for GIFT. A maximum
of six eggs were transferred. The ova were placed
in human tubal fluid media with 7.5% maternal
serum in a tissue culture dish. If agreeable to the
couple, a sperm suspension with 50,000-100,000
progressive sperm/jul was also placed within the
dish containing these oocytes. Once all follicles
had been aspirated, the catheter was loaded with
100,000-200,000 progressive sperm and the
oocytes as previously described.2

Fallopian tube catheterization was performed
by gently grasping the antimesenteric serosa of
the fallopian tube with an atraumatic instrument.
The ostium of the tube could then be visualized
and manipulated. On occasion, several instru-
ments were required for this purpose. The fallo-
pian tube was cannulated with a small metal tube
passed through the aspirating needle cannula
(Figure 1). The GIFT catheter was then passed
through this guide. Every effort was made to
insert the catheter at least four cms. into the
fallopian tube before injecting the gametes. Only
tubes known to be patent and appearing normal
were cannulated.

All patients were discharged the day of the
procedure. Each received 25 mg. of progesterone
intramuscularly daily, beginning on the day of
gamete transfer. This was continued until eight
weeks gestation if pregnant. A serum pregnancy
test was obtained 12 days after the procedure, and
if positive serial titers were evaluated. A bio-
chemical pregnancy was defined by consistent
elevation of the patient s HCG levels, but with
subsequent failure of gestational sac develop-
ment. A clinical pregnancy was confirmed by the
presence of a gestational sac on ultrasonography.

FIGURE 1. Insertion of the catheter into the distal fallo-
pian tube.

RESULTS

Nine of 27 (33%) completed GIFT cycles re-
sulted in a pregnancy, two were biochemical and
the remaining seven (26%) were clinical. There
were three twin gestations, all in patients having
transfer of six oocytes and there were no ectopic
pregnancies. Increasing the number of trans-
ferred oocytes was associated with progressively
higher pregnancy rates (Table 1). When four or
more mature or intermediate eggs were placed in
the oviducts, nine of 21 patients (43%) achieved
pregnancy. Pregnancy rates could not be defined
for lesser numbers. Only six patients had fewer
than four oocytes transferred during the GIFT
procedure, and four had either male autoim-
munity or male factor infertility, diagnoses associ-
ated with lower pregnancy rates.

TABLE I

Correlation of Oocyte Number to Pregnancy Rate

No. of Oocytes

No. of Cases

No. Pregnant

Percent

1-3

4-5

DISCUSSION

GIFT, gamete intrafallopian transfer, evolved
from the techniques established for in vitro fertil-
ization, and remarkably has doubled pregnancy
rates. The fallopian tubes must be normal, yet
patients with endometriosis, unexplained and cer-
vical factor infertility have achieved excellent
results as in the present study. This technique also

The Journal of the South Carolina Medical Association

GAMETE INTRAFALLOPIAN TRANSFER

holds promise for couples with oligospermia and
elevated sperm antibody levels.

Why GIFT has a higher success rate than IVF
and why it produces pregnancies in these infertile
couples is somewhat unclear. Several possible ex-
planations exist for the latter.3- 5 Transport of both
sperm and oocytes to the tubal ampulla, the nor-
mal site of fertilization, may be deficient. Lu-
teinized unruptured follicle syndrome with
oocyte entrapment may occur in some patients
and be unrecognized. However, several of the
patients who achieved a pregnancy in this GIFT
series had previously undergone serial ultrasounds
which excluded such a diagnosis. The increased
number of oocytes and sperm delivered to the site
of fertilization may also reduce possible impair-
ment of fertility secondary to defective gametes.
Certainly the diagnosis of unexplained infertility
includes all of these possibilities.

We attribute the excellent pregnancy rate re-
ported in this series to the following: strict ad-
herence to selection criteria; transfer in most cases
of an optimal number (four to six) of oocytes;4- 6
deposition of gametes at least four cms. within the
fallopian tube when possible; and development of
a GIFT program within an active and successful
IVF program. The skilled personnel, unique
equipment, and complex laboratory procedures
utilized in IVF are also generally required for
GIFT.

A new procedure combines ultrasound-di-
rected oocyte retrieval, in vitro fertilization, and
intra-tubal transfer of either pronuclear stage
oocytes (PROST) or tubal embryo transfer.7 These
combined techniques allow visualization of fertil-
ization and have unique applications for patients
suffering from severe oligospermia, asthenosper-
mia, or antisperm antibodies. Their success rates

when fertilization occurs are comparable to those
of the GIFT procedure.

Lastly, it may soon be possible to perform GIFT
without conducting laparoscopy. Vaginal ultra-
sound directed oocyte retrievals are now the stan-
dard for IVF. Ultrasound-guided tubal cannula-
tion with transfer of eggs and sperm has been
performed experimentally.8 If this approach is
successful, it would be possible to perform GIFT
in a non-operative manner. □

ADDENDUM

Between November, 1987 and December,
1988, 46 GIFT cycles were completed. Nineteen
pregnancies were achieved (41.3%). The clinical
pregnancy rate was 34.8%.

REFERENCES

1. Medical Research International, The American Fertility-
Society Assisted Reproductive Technology Group: In vitro
fertilization embryo transfer in the United States: 1985 and
1986 results from the National IYF/ET Registry. Fertil
Steril 49:212, 1988.

2. Asch RH. Ellsworth LR. Balmaceda VP: Pregnancy follow-
ing translaparoscopic gamete intrafallopian transfer
(GIFT). Lancet 2:1034, 1984.

3. Mollov D, Speirs A, DuPlessis Y, et al: A laparoscopic
approach to a program of gamete intrafallopian transfer.
Fertil Steril 47:289, 1987.

4. Nemiro JS, McGaughey RW: An alternative to in vitro
fertilization embryo transfer: The successful transfer of
human oocytes and spermatazoa to the distal oviduct. Fertil
Steril 46:644, 1986.

5. Asch RH, Balmaceda VP, Ellsworth LR, et al: Preliminary-
experiments with gamete intrafallopian transfer (GIFT).
Fertil Steril 45:366, 1986.

6. Craft I, Brinsden P. Simons FP: How many oocytes/em-
brvos should be transferred? Lancet 2:109, 1987.

7. Yovich JC, Yovich JM, Edirisinghe WR: The relative
chance of pregnancy following tubal or uterine transfer
procedures. Fertil Steril 49:858, 1988.

8. Jansen RPS, Anderson JC: Catheterization of the fallopian
tubes from the vagina. Lancet 2:309, 1987.

February- 1989

UPDATE ON HOSPITALIZED PESTICIDE
POISONINGS IN SOUTH CAROLINA, 1983-1987*

STANLEY H. SCHUMAN, M.D., Dr. P.H.**
NORRIS H. WHITLOCK, M.S.

SAMUEL T. CALDWELL, M.A.

PAUL M. HORTON, Ph.D.

This report identifies details of current pesti-
cide poisonings from hospital records. Typical or
unusual cases provide case histories for educating
pesticide users and health care professionals. Six-
teen-year trends of hospitalized poisonings are
analyzed for the period 1971-1987. h 2

METHODS

Seventy-six (76) general care hospitals in South
Carolina were contacted by letter. All hospitals
except one agreed to cooperate. Each medical
records department was asked to perform a rec-
ords search for 1983-1987 for the following ICD-9
diagnostic codes: 989.2 (chlorinated pesticides),

989.3 (cholinesterase inhibiting pesticides) and

989.4 (other pesticides). Sixty-one hospitals identi-
fied cases during the period of study. Epi-
demiologic data were abstracted from each rec-
ord by a member of the Agromedicine Program
staff or by the record librarian in five of the
hospitals.

RESULTS AND DISCUSSION

There were 312 admissions for pesticide poison-
ing during 1983-1987 as listed by exposure cate-
gory in Table 1. Ten cases (3%) are listed as
“undetermined” because their medical records
were not available for review.

N on-occupational Exposures

Non-occupational poisonings accounted for
50% of all cases and accidental poisonings in chil-
dren (30%) led all exposure categories. The home
environment was the place of poisoning for 87 of

0 From the Agromedicine Program of Clemson University
and the Medical University of South Carolina.

Address correspondence to Dr. Schuman at the
Agromedicine Program, Department of Family Medi-
cine, Medical University of South Carolina, 171 Ashley
Avenue, Charleston, SC 29425.

the 94 pesticide poisonings in children while seven
cases were associated with farming. Forty-five
cases in the home resulted from children having
access to pesticide containers, five of which were
soft drink or milk bottles in which pesticides were
stored. Thirty-four poisonings resulted from the
access of children to recently treated areas of the
home with 18 of the children ingesting rodent
baits. Two children were poisoned when given a
pesticide by parents who thought the chemical
was a medication. One child was hospitalized
after wearing tennis shoes that had been sprayed
with an organophosphate to kill fire ants. The
circumstances of five children poisoned in the
home could not be determined because their med-
ical records did not indicate the source of
exposure.

Of the seven children exposed to agricultural
pesticides, three had access to commercial con-
tainers. One child was hospitalized after playing
in a field recently sprayed with an organophos-
phate insecticide. Three siblings were severely
poisoned after their home was treated for cock-
roaches with an undiluted cotton insecticide (di-
crotophos) taken from a farm and used by the
parents.

The home was also the setting for 31 non-
occupational poisonings in adults. Thirty cases
involved exposure during application; 14 to gar-
dens or yards and 16 to dwellings. Thirty-one
other adults were poisoned with pesticides, but
were not exposed to home or garden applications.
These included eleven volunteer fire fighters who
were admitted to a hospital after extinguishing a
pesticide warehouse fire, five adults who were
hospitalized after they sprayed themselves with
an aerosol which they mistook for mosquito re-
pellant, five pet owners who became ill after
giving their dogs flea dips or shampoos, four
adults who were poisoned after drinking pesti-
cides which had been transferred to soft drink

The Journal of the South Carolina Medical Association

PESTICIDE POISONINGS

TABLE 1

312 Hospitalized Pesticide Poisonings in South
Carolina by Exposure Category, 1983-1987

Exposure

Category

1983

1984

Hospitalizations

1985

1986

1987

Total

n/%

Non-occupational:

Child

94/30

Adult

62/20

Occupational:

Ag. Related

50/16

Other

12/04

Intentional

84/27

Undetermined

10/03

Total

312/100

bottles and six who ingested pesticides while un-
der the influence of alcohol.

Occupational Exposures

Occupational exposures were documented in
20% of the cases. Forty-nine admissions (16%)
were related to agriculture with 41 farm workers
hospitalized following exposure during applica-
tion. Five agricultural workers were poisoned as a
result of exposure to spills from mixing/loading
operations. Three workers accidentally ingested
pesticides, one involved a chemical which had
been transferred to a soft drink bottle, and two
patients drank water from a contaminated irriga-
tion ditch.

Twelve of the occupational poisonings were not
related to agriculture. Two of the cases worked for
a pesticide company formulating synthetic
pyrethroids, two were construction laborers ex-
posed to pesticides and eight were either full or
part-time structural pest control operators.

Intentional Exposures

Intentional poisonings accounted for 27% of all
hospitalized cases, 80 of whom were suicidal (two
died) and five unsuccessful homicide attempts.
One death was due to the ingestion of diazinon, an
organophosphate insecticide, and the other death
was due to the ingestion of paraquat, a dipyridyl
herbicide which causes proliferative changes in
the lungs.

Chemical Class

Table 2 lists the categories of patient exposure

by chemical class of the intoxicant. Thirty-five
pesticides were not identified in the medical
records.

Insecticides accounted for 77% (n = 238) of the
poisonings. The organophosphate class of insec-
ticides dominated with 56% of the total. Diazinon,
malathion and chlorpyrifos were the leading
organophosphates in both non-occupational and
intentional categories (n = 68). Parathion and
mevinphos led the agricultural poisonings with a
total of 15 cases.

Carbamate insecticides accounted for 7%
(n = 21) of the cases with nine occurring in the
agricultural related category. Typical of this
chemical class are aldicarb, carbaryl, carbofuran
and methomyl.

Organochlorine insecticides also accounted for
7% of the total, however 11 cases were attributed
to aldrin and all of these were fire fighters exposed
to a single warehouse fire.

The synthetic pyrethroids and other insecticide
chemical classes respectively accounted for five
cases and two percent of the total.

Twenty-one cases (7%) of rodenticide poison-
ing were found in the child and intentional cate-
gories. Anticoagulants such as warfarin and
coumadin accounted for the 21 cases.

Herbicides hospitalized only seven patients.
Two were due to exposure in agriculture and two
were non-occupational adults. There were three
suicide attempts, one of which was fatal with
paraquat.

February 1989

PESTICIDE POISONINGS

TABLE 2

Pesticide Exposure Categories Identified by Chemical Class1

Exposure Category

Chemical Non-Occupational Occupational Total

Class Child Adult Agric. Other Intentional n/ %

Insecticides2:

174/56

21/ 7

22/ 7

15/ 5

6/ 2

Rodenticides

22/ 7

Herbicides

7/ 2

Not Specified

35/11

Total

302/97

1 n = 302, 10 of 312 patient records were not available for review

2 OP = organophosphates, CB = carbamates, OC = organoehlorines, SP = synthetic pyrethroids, OT = other insecticide
chemical classes

County of Occurrence

Florence and four adjoining counties (Horry,
Darlington, Dillon and Marion) in the Pee Dee
accounted for 20% of the state’s pesticide poison-
ing hospitalizations. Eight counties (Abbeville,
Barnwell, Calhoun, Fairfield, McCormick, New-
berry, Saluda and Union) had no hospitalizations
for pesticide poisoning during the period of study.
Lexington County led all other counties with a
total of 40 cases. Lexington County had the most
adult non-occupational cases (n = 13) and tied in
number of cases with other counties in the follow-
ing exposure categories: Sumter County / home
application (n = 4), Richland County / intentional
(n = 9) and Orangeburg County / child (n = 7).
Horry County led in the occupational category for
agricultural related cases with a total of six.

Patient Profile

The typical patient was a white male, except in
the child category where non-whites were slightly
more frequent. The average age of children hospi-
talized was three years, while the average of the
other exposure categories ranged from 32 to 47
years. Days hospitalized ranged from two for
child poisonings to five for intentional cases, re-
flecting psychiatric evaluation and longer hospital
stay. Only 15% of all hospitalizations had specific

laboratory tests for pesticide poisoning (RBC or
plasma cholinesterase determinations or gas chro-
matographic pesticide residue analyses). Death
was rare, accounting for only 0.6% of all cases.

DISCUSSION

Cases of pesticide poisoning admitted to South
Carolina hospitals have decreased by 20% from an
average of 78.5 per year for the period of
1979-1982 to 62.4 for the period of 1983-1987.
Trends over the past nine years are detailed in
Figure 1. These are small numbers. For example.

The Journal of the South Carolina Medical Association

PESTICIDE POISONINGS

TABLE 3

Sixteen Year Surveillance of
Pesticide Poisonings in South Carolina, 1971-87°

Parameters

Study l1

Study 22

Study 3

Time Period

1971-73

1979-82

1983-87

Years (n)

Hospitals (n)

Cases (n)

117

314

312

Average Cases/ Year

39.0

78.5

62.4

Deaths (n)

Case Fatality (%)

2.2

% Occupational

% Non-Occupational

(% Children)

(31)

(16)

(30)

% Intentional

0 ICD Codes: 989.2, 989.3, 989.4 (see text)

’• 2: See References.

child poisonings vary considerably from year to
year (highest in 1981 and lowest in 1982 and
1987). The percent of non-occupational pesticide
poisonings has remained about the same while the
percent of intentional poisonings increased from
16% to 27% and occupational cases decreased
from 25% to 20% (Table 3). The continued down-
ward shift in occupational poisonings suggests the
value of pesticide safety training and pesticide use
certification programs in agriculture and other
pesticide use occupations. The need for educa-
tional programs aimed at the homeowner, gar-
dener and others is also clear. Approximately
thirty child and adult non-occupational hospi-
talizations could be eliminated each year if the
homeowner followed pesticide label directions for
usage and safety. Others in the community re-
quire special pesticide training; for example, 11
volunteer fire fighters were hospitalized as a result
of a warehouse fire.

There are several hypotheses for the overall
reduction in pesticide poisoning hospitalizations.
The benefit of applicator training programs can-
not be overstated. The classification of the more
toxic pesticides into a restricted use category al-
lows only certified users to purchase and use them,
reducing the exposure of amateurs. Psychiatrists
advise that depressed or suicidal patients be re-
stricted from access to pesticides.

The use of the synthetic pyrethroid insecticides

is on the increase. While generally less toxic to
man than either the organophosphates and carba-
mates, physicians should be aware of the syn-
ergistic action of synthetic pyrethroids with
neurotoxicity of organophosphates. This has been
documented in animal studies3 and is suspected in
one recent case4 investigated by the authors.

Although hospitalized cases of pesticide poison-
ing are declining, one must remember that less
severe cases are not counted in this study.
Pesticide cases involving allergy, dermatoses or
outpatient treatment are not enumerated. The
first published estimate1 of the outpatient/inpa-
tient ratio for pesticide poisonings in South Caro-
lina was 15/1. An unpublished study in 1979
found that the ratio had declined and that for each
hospitalization for pesticide poisoning, there were
10 cases treated on an outpatient basis.5

Acute pesticide poisoning is a highly prevent-
able cause of hospitalization among children and
adults. The long term consequences of acute
organophosphate poisoning are speculated upon
in a recently published case/control study.6

SUMMARY

Three hundred twelve hospitalizations for
pesticide poisoning occurred in South Carolina
during 1983-1987. This represents a twenty per-
cent decline from an average of 78.5 cases hospi-

Februarv 1989

PESTICIDE POISONINGS

talized per year (1979-1982) to 62.4 cases hospital-
ized per year currently. Non-occupational poison-
ings accounted for one-half of the hospitalizations
while 20% were related to occupation. Intentional
poisonings represented 27% of the total. Two
deaths as a result of suicide occurred during the
four year period giving a case fatality of <1.0%.
This five year update reenforces the need for
continued education and prevention efforts. □

ACKNOWLEDGMENTS

The authors wish to thank the cooperating hospitals for their
assistance and sophomore medical students Neville Bennett,
Craig Merrill and Rachelle Paul who performed most of the
field work for this study.

REFERENCES

1. Caldwell ST and Watson MT: Hospital survey of acute
pesticide poisoning in South Carolina 1971-1973. JSC Med
Assoc 71:249-252, 1975.

2. Schuman SH, Caldwell ST, Whitlock NH, Brittain JA:
Etiology of hospitalized pesticide poisoning in South Caro-
lina, 1979-1982. J S C Med Assoc 82:73-77, 1986.

3. Gaughan LC, Engel JL, Casida JE: Pesticide interactions:
Effects of organophosphorus pesticides on the metabolism,
toxicity, and persistence of selected pyrethroid insecticides.
Pest Biochem Phys 14:81-85, 1980.

4. Personal communication with Dr. R E. Adler, Charleston,

S.C., 1988. A clinical case of combined exposure to a syn-
thetic pyrethroid and an organophosphate insecticide re-
sulting in a pediatric psychiatric hospitalization.

5. Unpublished data (1979). South Carolina Pesticide Hazard
Assessment Program, MUSC, 171 Ashley Avenue, Charles-
ton, S.C. 29425.

6. Savage EP, Keefe TJ, Mounce LM, et al: Chronic neu-
rological sequelae of acute organophosphate pesticide poi-
soning. Arch Environ Health 43:38-45, 1988.

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The Journal of the South Carolina Medical Association

NEWSLETTER

FEBRUARY 1989

HIGHLIGHTS OF JANUARY BOARD OF TRUSTEES MEETING

The Board of Trustees appointed John W. Simmons, MD, and William
J. Goudelock, MD, as SCMA representatives to the Board of
Directors of Medical Review of North Carolina.

Dr. Rowland reported that SCMA will be introducing a Medical
Review Bill in the SC General Assembly. The legislation will
reguire any physician doing review in South Carolina to be
licensed to practice medicine in this state.

Board members discussed Free Choice Press Conferences held by the
SC Chiropractors' Association to call for mandated chiropractic
benefits. The SCMA distributed position papers to all reporters
on this subject.

The SCMA Committee on Aging will look into current issues and
commercials on home health care products.

The Leonard Douglas Memorial Lecture speaker was announced.
Speaking to the SCMA House of Delegates on Thursday, April 27,
will be Nancy Dickey, MD, former chairman and current member of
the AMA Council on Ethical and Judicial Affairs.

It was announced that the PCF Board has a 24 million dollar
reserve and will institute a premium reduction in March 1989.
For physicians who have been members of the JUA for four years,
the rate will be reduced from 40 percent to 3 0 percent of the
JUA premium. In addition, the PCF has approved a 32 percent
decrease for state-employed physicians due to the million dollar
cap enacted in the Tort Claims Act of 1988. The JUA has reduced
the rates to Free Clinics as a result of the Charitable Immunity
Act of 1988.

MEDICARE UPDATE

ICD-9-CM Diagnostic Codes

EFFECTIVE APRIL 1, PHYSICIANS WILL BE REQUIRED TO SUPPLY AN ICD-
9 -CM DIAGNOSTIC CODE FOR EACH LINE ITEM BILLED ON MEDICARE
CLAIMS. EFFECTIVE JUNE 1, ASSIGNED CLAIMS WILL BE DENIED IF THEY
DO NOT CONTAIN THESE CODES. IN ADDITION, PHYSICIANS WILL BE
SUBJECT TO FINES AND SANCTIONS IF THESE ARE NOT PROVIDED TO
PATIENTS FOR UNASSIGNED CLAIMS. A Medicare Advisory will be
issued in the near future which will provide details on this new
requirement.

ICD-9-CM coding books can be purchased from the Government
Printing Office, Superintendent of Documents, Washington, DC
20402-9325, (202) 783-3238.

3 volume paperback
3 volume hardback
Official Authorized Addendum
HIV Infection Codes

1988 Price
$29.00
$40.00
$ 3.75
$ 1.00

Stock Number

017-022-00715-1

017-022-00714-2

017-060-00241-7

017-022-01045-3

January 1989 Medicare Advisory

This Medicare Advisory contains important information which
should be reviewed by you and your billing staff. Some
highlights include clarification that ambulatory blood pressure
monitoring is not a covered Medicare service? instructions that
all claims for digital (data compression) and analog (tape)
holter monitors must be filed under procedure codes Q0019-Q0026
with either a QD or QT modifier? new radiation therapy and
anatomical laboratory billing instructions? and further
clarification on the prohibition against marking up charges from
the outside supplier for purchased diagnostic tests.

Secondary Pavor

The AMA has requested that Medicare pay physicians directly on
all assigned claims as a practical way to avert non-payment
problems that have arisen from secondary requirements.

The AMA has requested that physicians relate the nature and
extent of any problems they have experienced with Medicare
Secondary Payor requirements in order to assist the AMA in
documenting the need for this request. Please send this
information to Barbara Whittaker, SCMA, who will forward it to
the AMA.

MEDICAID UPDATE

Pediatric CPT-4 Codes

SC State Health & Human Services Finance Commission has furnished
SC pediatricians with a list of CPT-4 codes and Medicaid
supplemental codes with their respective definitions,
reimbursement rates and notes that may help in determining the
appropriate code to use when billing Medicaid. This should
assist pediatricians and their office staffs who provide medical
care to Medicaid eligible newborns, children and adolescents with
coding and filing for services rendered.

If you did not receive the memorandum containing this information
or if you have questions, you may call (803) 253-6134 or write
to: HHSFC , Department of Physician Services, PO Box 8206,
Columbia, SC 29202-8206. A copy of the memorandum and list of
codes are also available through the SCMA office. Call 798-6207
or 1-800-327-1021 and ask for Melanie McLendon or Kim Fox.

Healthy Mothers - Healthy Futures Program

Effective January 1, 1989, HHSFC implemented the Healthy Mothers
- Healthy Futures Program which includes increased Medicaid
reimbursement for maternal care that incorporates health
education, referral to community support programs and follow up
for missed appointments into a comprehensive prenatal plan of
care. If the physician chooses to participate by agreeing to
provide health education referrals to WIC, and follow-up
telephone calls to prenatal Medicaid clients who missed
appointments, he will be reimbursed at an enhanced rate for these
additional services.

The appropriate procedure codes which include the enhanced
services are listed below, along with codes for services which do
not include the educational services and referrals. The codes
which are marked with an asterisk must be used if a physician
does not wish to participate.

Service Procedure Code Medicaid Rate

Initial Maternal Care
(OB exam) with additional
services

SOHO

$100.00

Initial Maternal Care
(OB exam) without additional
services

S1500*

$ 50.00

Antepartum Care with
additional services

S0112

$ 25.00

Antepartum Care without
additional services

59420*

$ 18.00

Postpartum Care with
additional services

S0114

$ 25.00

Postpartum Care without
additional services

59430*

$ 18.00

All delivery services are reimbursable at the new rate, effective
January 1, 1989.

Vaginal Delivery 59410 $600.00

Cesarean Section 59500, 59520 $700.00

or 59540

A thorough explanation of the program is being mailed to all
physicians. If you have questions in the meantime, please call
Darlynn Thomas or Kathi Peebles at 253-6140 or 6141, or Mr. Bob
McRae at 253-4063.

Claim Requirement Update

The SC Medicaid program issues a unique six-digit ID number to
all physicians enrolled in the program. If your office is
submitting claims to the Medicaid office, you must put your
individual six-digit ID number on the claim form in field 31. If
you are billing under a group number, you should put this number
in field 31 and your individual ID number in field 24 C (next to
the procedure code field) .

HHSFC will help your office identify your six-digit number and
will continue to provide help to your staff with any billing
problems they may have. Please call 253-6134 for assistance. All
eligible Medicaid recipients are given a unique 10-digit ID
number. This number is printed on their Medicaid card. Please
remember to check your patient's card every month to ensure
eligibility.

PRO UPDATE: PRIOR APPROVAL INFORMATION

Effective for surgeries scheduled March 1, 1989 and thereafter,
the following prior approval procedures will apply:

Medicaid : ALL ELECTIVE procedures, whether inpatient or
outpatient or in ambulatory surgery setting, require preprocedure
review for the following: lens extraction, nasal septal
reconstruction, coronary bypass and hysterectomy (written request
required) . Direct written request for hysterectomies to Internal
Review, Carolina Medical Review, PO Box 37309, Raleigh, NC 27627.
Hysterectomy request forms must be received 15 days prior to
planned date of surgery and DSS form 1729 (Acknowledgment of
Receipt of Hysterectomy Information) must be attached. In
addition, all inpatient admissions for procedures on the minor
surgical list in the Medicaid Manual, as well as cardiac
catheterization, require prior authorization from Carolina
Medical Review. URGENT AND EMERGENT admissions will be reviewed
retrospectively .

Medicare: ALL ELECTIVE procedures, whether inpatient, outpatient
or in ambulatory surgery setting, require prior approval for the
following: permanent cardiac pacemaker implantation and
replacement, cataract extraction (lens procedures) , total
cholecystectomy, inguinal hernia, major joint replacement,
transluminal coronary angioplasty, transurethral prostatectomy,
and hysterectomy (abdominal and vaginal) . ALL NON-ELECTIVE
(EMERGENT) cases will be reviewed on a postprocedure, prepayment
basis. APPROPRIATE AND TIMELY MEDICAL CARE MUST NOT BE DELAYED
TO OBTAIN PRIOR APPROVAL.

Telephone requests for Medicaid and Medicare prepapprovals can be
made, beginning February 13, Monday through Friday, 8:00 am-5:00
pm to 1-800-331-4690.

HEALTHCARE ISSUES FACING CONGRESS

The 101st Congress will address the following healthcare issues:

- regulation of financial relationships between physicians and
enterprises to which they refer patients. The proposed
legislation goes beyond the Medicare anti-kickback regulations
still pending in the Department of Health and Human Services.

- health insurance for the uninsured which would require
employers to provide a minimum level of health insurance to all
workers and their dependents. The president intends to offer a
Medicaid buy-in program for the uninsured working poor and
increase Medicaid spending for ^pregnant women and children.

- long term care coverage for the elderly. At a cost of $20
billion, this legislation proposes changes in coverage for
nursing home and home care for Medicare beneficiaries.

Medicare reform will be a dominant issue because of the pressure
to control healthcare costs. Congress is expected to hear
testimony from several groups on Harvard's Resource-Based
Relative Value Study.

The present budget proposal for FY90 contains a $5 billion cut in
the Medicare program and an additional $1 billion cut in the
Medicaid program. The proposed Medicare budget contains a fee
freeze for all non-primary care services in 1990, a 10 percent
drop in radiology and anesthesiology fee schedules in 1990, a $90
million reduction in surgical procedures, and a fee reduction and
fee freeze for clinical lab services in 1990.

Morehouse Medical School President, Louis Sullivan, MD, is
proposed to be the new secretary of the Department of Health and
Human Services. Dr. Sullivan's priorities are drug abuse,
preventive medicine, minority health, biomedical research and
healthcare costs. He opposes abortion except in cases of rape or
incest or when a woman's life is in danger. Dr. Sullivan has been
active in AMA and Medical Association of Georgia affairs for many
years. A hematologist, he received his MD degree from the Boston
University School of Medicine in 1958.

LAWYER-PHYSICIAN RELATIONSHIP COMMITTEE

The Lawyer-Physician Relationship Committee of the SC Bar
Association on January 26 sponsored a panel discussion regarding
physician testimony in personal injury court cases. The panel,
consisting of three physicians and three attorneys, supported the
use of videotaped testimony by physicians for use instead of
actual in-court appearances. Plans are being developed for a
joint CME-CLEl presentation during the SCMA Annual Meeting in
Charleston.

MEDICAL LIABILITY PURCHASING GROUP. INC.

You should be alerted to the fact that the Medical Liability

Purchasing Group, Inc., is contacting SC physicians to solicit
them for medical liability coverage. According to the SC
Department of Insurance, purchases in SC would be effected in The
Casualty Assurance Risk Insurance Brokerage Company which is not
recognized as an eligible surplus lines insurer. The Medical
Liability Purchasing Group, Inc., has been instructed to
discontinue the solicitation to residents of SC until the company
is duly qualified and the purchasing group is properly
registered.

CHAMPUS ANNOUNCES NEW CLAIMS MAILING ADDRESSES

Military families and SC healthcare providers should mail CHAMPUS
claims to a new address effective February 1, 1989. On February
1, Blue Cross and Blue Shield of SC took over claims processing
for South Carolina. The mailing address for all CHAMPUS and
CHAMPVA claims is CHAM PU S/ CHAM PVA, Blue Cross and Blue Shield of
South Carolina, PO Box 100502, Florence, SC 29501-0502. The
toll-free telephone number is 1-800-476-8500.

CONFERENCES TO BE HELD

The 1989 Annual Spring Meeting of the South Carolina Association
of Medical Managers will be held March 30 - April 1 at the Ocean
Creek Resort, Myrtle Beach, SC. The meeting topic is "Your Role
in Managing a Medical Practice." For further information, please
contact Mr. Robert Hendrickson in Greenville at 242-4122 or Mrs.
Betty Hodge in Charleston at 792-4762.

The Emory University AIDS Training Network will be holding AIDS-
related conferences as follows:

"Women and AIDS" - May 19 in Myrtle Beach. Registration is

$10.00.

"AIDS in Your Practice - Case Management in HIV Disease for the
Primary Care Physician" - March 18 on Kiawah Island and May 13 in
Asheville. Registration is $100.00.

For additional information, please contact the Emory AIDS
Network, 735 Gatewood Rd. , NE, Atlanta, GA 30322. Telephone:
(404) 727-2929.

CAPSULES

Charles R. Duncan, Jr. , MD, Greenville, was presented an
honorary membership in the South Carolia Hospital Association,
"for his leadership in the healthcare field and the many
contributions he has made to the betterment of patient care."

Harold E. Jervey, Jr., MD, Columbia, has been appointed as an
advisor to the School of Medicine and personal advisor to the
Rector of Universidad Central del Este in San Pedro de Macoris,
Dominican Republic.

CHRONIC HEPATITIS AND INDOLENT
CIRRHOSIS DUE TO METHYLDOPA: THE
BOTTOM OF THE ICEBERG?*

WILLIAM M. LEE, M.D.**

WILLIAM T. DENTON, M.D.

Methyldopa has been one of the most com-
monly prescribed antihypertensive drugs in the
United States for many years. Asymptomatic ele-
vations of transaminases in patients receiving
methyldopa have been recognized since its
clinical trials in the 1960’s, and were noted in as
many as six percent1 of patients taking meth-
yldopa, but were considered to be of little conse-
quence in the absence of symptoms. With further
clinical experience, the agent was noted to cause
both an acute illness indistinguishable from viral
hepatitis, and a chronic hepatitis resembling auto-
immune chronic active hepatitis.2- 3 In some cases,
rechallenge with the drug resulted in severe 5
and even fatal reactions.6 The abrupt onset of
these latter forms of liver injury and their relative
severity has suggested that an idiosyncratic im-
mune-mediated reaction was involved." Exten-
sive studies on the pathogenesis of this condition
are lacking, and even less data are available con-
cerning those patients with mild and asymptom-
atic AST elevations. If a more occult form of drug-
induced injury were to lead to cirrhosis in certain
individuals it would occur only after several years
of treatment and such cases would be likely to
appear only after the drug has been in clinical use
for a relatively long period of time. This has been
our recent experience with confirmed and sus-
pected cases of methyldopa-induced hepatotox-
icity. The present study was prompted by a
patient presenting with ascites and variceal hem-
orrhage who had received methyldopa for five
years. Our review of other cases of suspected
methyldopa toxicity over a three-year period led

° From the Gastroenterology Division, Department of Medi-
cine, Medical University of South Carolina, Charleston.
This work was supported in part by State of South Carolina
Biomedical Research Grants GR44 and GR55 and by The
Houghton Foundation, Corning, NY.

Address correspondence to Dr. Lee at the Gastroenterology-
Division, Medical University of South Carolina, 171 Ashley
Avenue, Charleston, SC 29425.

to the identification of five additional patients
with evidence of methyldopa-induced liver dis-
ease, most of whom suffered from indolent,
asymptomatic liver injury leading to cirrhosis.

METHODS

All cases of suspected drug-induced liver injury
seen by the Gastroenterology Service at the Medi-
cal University Hospital, Charleston, South Caro-
lina, over a two and one-half year period were
reviewed. Of 15 cases in which drug-related dis-
ease was likely, six were identified in which meth-
yldopa was the presumed implicated agent.

Cases accepted for consideration were divided
into three categories defined as follows:

1. Definite: A strong temporal relationship of
the illness to ingestion of methyldopa was
present, other suspected causes of hepatic
injury were absent, and a positive rechal-
lenge with the medication had occurred.

2. Probable: A strong temporal relationship
with methyldopa existed, rapid fall of trans-
aminase levels occurred after discontinua-
tion of the drug, and no other suspected
causes of hepatic injury were known. No
rechallenge was performed.

3. Possible: A temporal relationship with
methyldopa was established but a less dra-
matic decrease in enzyme levels occurred
after discontinuation of methyldopa, no
other obvious causes of hepatotoxicity were
apparent, and no rechallenge was per-
formed.

All patients were tested for hepatitis B viral
markers including HBsAg, anti-HBs and anti-
HBc and were found to be normal. Mitochondrial
antibody, alpha-l-antitrypsin, ferritin and cerulo-
plasmin levels were also obtained, and were found
to be normal or negative in all instances. Testing
for the presence of antibodies to smooth muscle
(ASMA) in serum was also performed.

February 1989

METHYLDOPA HEPATITIS

TABLE 1. Clinical and Laboratory Data for Six Patients
with Presumed Methyldopa Hepatotoxicity

Duration Bilirubin AST Aik Phos ASMA

Pt. No. of Rx Age Sex mg/dl IU/L IU/L Titer Ascites

Definite

Probable

4 mon

11.0

1700

247

1/160

3 yrs

13.0

500

325

1/160

—

Possible

1 yrs

1.0

545

430

1/40

—

5 yrs

3.1

121

1/20

9 yrs

1.1

248

1/80

4 yrs

0.3

280

1/80

CASE SUMMARIES

Data on the six patients suspected of having
disease secondary to methyldopa are summarized
in Table 1. Except for patient No. 1, all patients
had been taking methyldopa for one year or
longer. All were seropositive for antibodies to
smooth muscle. Five of six had histologic evidence
of cirrhosis.

Patient No. 1 was classified as a “definite”
example of methyldopa-induced liver injury. She
was a 53-year-old white housewife who had taken
methyldopa in combination with hydrochlorothi-
azide for four months when she developed
painless jaundice and constitutional symptoms.
AST level was initially 1700 IU/L falling to 200
IU/L (normal <25) over five days following ces-
sation of methyldopa. Because the diagnosis was
uncertain, she was referred for further evaluation.
Over the intervening two-week period her jaun-
dice had resolved. An ERCP was performed and
was normal, and a liver biopsy demonstrated re-
solving chronic active hepatitis (CAH) without
fibrosis. She was discharged with the diagnosis of
probable methyldopa-induced hepatitis. Upon re-
turn to her home, she had a rapid relapse of
symptoms with increased transaminase levels
(AST 750) five days after inadvertent resumption
of the methyldopa-hydrochlorothiazide combina-
tion. Once this was recognized, the drug was
discontinued and her symptoms and laboratory
abnormalities resolved completely.

The “probable” group includes two patients
who were not rechallenged but had courses very
suggestive of methyldopa injury with rapid im-

provement in AST values on discontinuation of
methyldopa. Patient No. 2 was a 69-year-old
woman who was without complaints but was
noted to be icteric on a routine visit to the Hyper-
tension Clinic. No predisposing factors were elic-
ited other than the use of methyldopa for three
years. Initial serum bilirubin was 13 mg/dl (nor-
mal <1) and her AST was 500 IU/L. A per-
cutaneous cholangiogram showed no obstruction
and a liver biopsy revealed CAH with established
cirrhosis (Figure la). Her AST and bilirubin levels
declined rapidly upon withdrawal of methyldopa.
One year after initiation of methyldopa therapy,
patient No. 3, a 53-year-old white woman, was
asymptomatic, but was noted to have markedly
elevated transaminases (AST 545) on a routine
screening laboratory examination. Although she
had received one unit of packed red blood cells
nine months prior to admission, the rapid decline
in serum AST levels upon discontinuation of
methyldopa was more suggestive of methyldopa
hepatotoxicity. Liver biopsy disclosed CAH with
fibrosis and early cirrhotic features. This patient
has remained symptom-free with normal AST
levels during the subsequent two years.

The three “possible” cases were initially seen
for management of ascites after prolonged meth-
yldopa therapy and each had a negative evalua-
tion for other causes of liver disease. Patient No. 4,
a 50-year-old man, developed ascites after more
than five years on methyldopa. He denied alcohol
intake. Initial bilirubin was 3.1 gm/dl, AST 89
IU/L, and alkaline phosphatase 121 IU/L (nor-
mal <110). Gamma globulin level was increased

The Journal of the South Carolina Medical Association

METHYLDOPA HEPATITIS

FIGURE la. Liver biopsy on patient #2 showing portal
tract expansion, moderate infiltration with mononuclear
cells and piece-meal necrosis. A cirrhotic nodule is present
in right half of figure. (Masson’s trichrome, HOx)

FIGURE lb. Liver biopsy from patient #4. A more estab-
lished cirrhosis is present with less dramatic inflammatory
component. Some areas of piece-meal necrosis are present
(arrow). (Hematoxylin and eosin, llOx)

to 1.98 gm/dl and SMA was positive at 1:20.
Bilirubin and AST levels fell to 1.9 and 65 respec-
tively when methyldopa was discontinued. Liver
biopsy revealed CAH with established cirrhosis
(Figure lb). Five months later, the patient devel-
oped variceal bleeding and died following a por-
tacaval shunt. Patient No. 5 was a 60-year-old
black female who had received methyldopa and
hydrochlorothiazide in combination for nearly
ten years. Ascites developed in the month prior to
admission. No other etiology of her disease was
evident. SMA was positive at 1:80 and gamma
globulin level was increased at 3.6 gm/dl. Liver
biopsy disclosed well-developed cirrhosis with
features of CAH. The initial AST level of 39 was
unchanged by discontinuation of methyldopa.
Patient No. 6 was a 40 year-old-white male who
admitted drinking modest amounts of alcohol
(two to four oz./day). After three years of meth-
yldopa and hydrochlorothiazide, he experienced
an episode clinically resembling acute viral hepa-

titis but viral markers were negative. At this time,
his AST level was 382 IU/L and serum bilirubin
1.6 gm/dl. He was continued on methyldopa for a
period of greater than one year afterwards with
persistent but less marked AST elevations (79 IU/
L) before the agent was discontinued. His liver
biopsy showed a pattern of mild CAH with cir-
rhosis; no features suggestive of alcoholic liver
disease were present. No significant change in
transaminase levels was noted on cessation of
therapy.

DISCUSSION

Our patients differ from those described pre-
viously with methyldopa-induced liver disease in
that five of the six had taken methyldopa for long
periods of time without apparent hepatotoxicity;
these five demonstrated cirrhosis on biopsy at the
time of presentation. Only one patient had classi-
cal chronic active hepatitis without cirrhosis, and
no case of subacute hepatic necrosis or acute hepa-

February 1989

METHYLDOPA HEPATITIS

titis was observed. At initial diagnosis, two pa-
tients were jaundiced, while in three ascites was
the presenting symptom. In previous reports of
methyldopa-induced liver damage, post-necrotic
cirrhosis was noted in follow-up in several cases
who had had severe acute liver damage; however,
cases with indolent liver damage leading to cir-
rhosis have not been extensively reported. Cir-
rhosis was noted to be present at diagnosis of
methyldopa-related liver disease in two of twenty
cases in a previous study.8 One patient had re-
ceived methyldopa for 38 weeks, but in the second
instance, methyldopa had been taken for only
three weeks and the cirrhosis was thought to rep-
resent a pre-existing condition.

It is difficult to be absolutely certain that meth-
yldopa was causative in the five cirrhotic patients,
since rechallenge with the offending drug was not
performed, and would not be considered ethical
while alternative agents were readily available.
Inadvertent rechallenge provided the one “defi-
nite” case (CAH without cirrhosis) in our series.
Thus the evidence for methyldopa-induced liver
injury in these cases, as in those described pre-
viously, is largely circumstantial. Rapid resolution
of AST levels with cessation of therapy is the next
best clue short of rechallenge, and this is further
strengthened if the liver biopsy features and
serologic tests are compatible with CAH. This
pattern was seen in cases two and three. However,
cases four through six, those with possible meth-
yldopa liver injury, are harder to prove and are
included only to suggest that the spectrum of liver
injury may be wider than we now recognize. The
problem of implicating a drug as a “low-grade”
hepatotoxin is compounded further in the case of
chronic indolent liver injury: enzyme levels can-
not be expected to improve dramatically on with-
drawal of the agent since they are not markedly
elevated to begin with. Similarly, dramatic im-
provement of symptoms will not be likely to
occur.

While AST levels are not reliable for monitor-
ing development of fibrosis and cirrhosis in pa-

tients treated with methotrexate,9 periodic AST
meaurement may be helpful in methyldopa-re-
lated liver injury, since all our patients at presen-
tation had elevated AST levels. Elevations of AST
were documented over a one year period prior to
discontinuation of methyldopa in one case (pa-
tient #6) in our series.

Of additional interest is the finding that all six
patients described in this report were on hydro-
chlorothiazide as well as methyldopa, either as a
separate agent or as the combination, Aldoril®.
This association has been present in several pre-
vious case reports of CAH related to meth-
yldopa.2' 3 It may be explained as the coincidental
administration of two common antihypertensive
agents; however, the possibility of synergistic tox-
icity cannot be excluded.

In summary, asymptomatic indolent liver in-
jury due to methyldopa eventuating in cirrhosis
may be the most common form of liver injury seen
due to this agent in the 1980’s. A firm diagnosis of
indolent methyldopa liver injury leading to cir-
rhosis is difficult to make and will require a care-
ful longitudinal study of larger numbers of
patients. Periodic screening for AST elevations
should facilitate the early recognition of meth-
yldopa-treated patients at risk before cirrhosis
ensues. We suggest that transaminase levels be
obtained prior to beginning therapy with meth-
yldopa, at three to six months intervals initially,
and at yearly intervals thereafter. AST elevations
prior to initiation of therapy should preclude use
of this agent. Asymptomatic AST elevations oc-
curring in patients on methyldopa should not be
ignored since CAH may be present despite ab-
sence of symptoms. When abnormalities are de-
tected, a liver biopsy may be indicated unless the
brevity of the drug use interval makes this unnec-
essary. For most patients with persistent AST ele-
vations, methyldopa should be discontinued and
AST levels monitored for evidence of resolution
while an alternate anti-hypertensive regimen is
undertaken. □

The Journal of the South Carolina Medical Association

REFERENCES

1. Elkington SG, Schreiber WM, Conn HO: Hepatic injury
caused by alphamethyldopa. Circulation. 1969:40:589-595.

2. Maddrey WC, Boitnott JK: Severe hepatitis from meth-
yldopa. Gastroenterology. 1975;68:351-360.

3. Rodman JS, Deutsch DJ. Gutman SI: Methyldopa hepatitis.
Am J Med. 1976;60:941-948.

4. Hoyumpa AM Jr. Cornell AM: Methyldopa hepatitis: report
of three cases. Am J Dig Dis. 1973;18:213-222.

5. Delpre G, Grinblat J. Kadisu V. et al: Immunological studies
in a case of hepatitis following methvldopa administration.
Am J Med Sci. 1979;277:207-213.

6. Goldstein GB, Lane KC Mistilis SP: Drug induced active
chronic hepatitis. Dig Dis. 1973:18:177-184.

7. Arranto AJ, Sotaniemi EA: Morphologic alterations in pa-
tients with alphamethyldopa induced liver damage after
short and long term exposure. Scandinavian J Gastro.
1981;16:853-872.

8. Toghill PJ, Smith PG. Benton P. Brown RC, Matthews HL:
Methyldopa liver damage. Brit Med J. 1974;3:545-548.

9. Weinstein GD. Roenigk HH. Maibach HI. et al: Psoriasis-
liver-methotrexate interactions. Arch Dermatol.
1973;108:36-42.

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Februarv 1989

HEALTH PROMOTION BELIEFS AND ATTITUDES
OF PHYSICIANS: A SURVEY OF TWO
COMMUNITIES IN SOUTH CAROLINA*

FRANCES C. WHEELER, Ph.D.
DANIEL T. LACKLAND, M.S.P.H.
JOHN V. RULLAN, M.D., M.P.H.

There is growing recognition that certain life-
style risk factors, such as smoking, alcohol and
drug misuse, poor nutrition, lack of physical ac-
tivity and stress, are major contributors to unnec-
essary morbidity and premature mortality in the
United States today. Although a variety of health
promoting behaviors have been linked to de-
creased morbidity and mortality,1 preventive
health practices are not considered optimal within
the population.2’ 3

Individuals must accept responsibility for re-
ducing their own risks, but physicians are thought
to be in a unique position to encourage and influ-
ence health behavior change. Physicians are con-
sidered by the public to be the single best, most
reliable and credible source of health informa-
tion.4 On the other hand, less is known about
physicians’ beliefs regarding health promotion
practices of their patients. Studies in Massachu-
setts5 and Maryland6 found that a large number of
physicians believe that health promotion is impor-
tant and that the physician can and should play an
important role in this area. To provide additional
information on this topic, for a southern, non-
urban population area, this paper examines health
promotion beliefs and attitudes of physicians in
two communities in South Carolina.

METHODS

A questionnaire was mailed in December,
1987, to 98 practicing physicians in Florence and
Anderson, South Carolina, with primary spe-
cialties in general practice, family practice, inter-
nal medicine, and obstetrics/gynecology. This
mailing was directed to all physicians whose prac-
tice was located in either of the two communities

° From the South Carolina Department of Health and En-
vironmental Control, 2600 Bull Street, Columbia, SC 29201
(address correspondence to Dr. Wheeler).

and whose primary specialty area was listed as
general practice, family practice, internal medi-
cine, or obstetrics/gynecology by the South Caro-
lina Medical Association. Follow-up mailings and
telephone calls were made to non-respondents. Of
the 98 physicians in the sample, 87 completed the
questionnaire, for an overall response rate of 89
percent.

The questionnaire, as used in previous studies,4’ 5
consisted of multiple-choice questions with scaled
responses. The following issues were covered: be-
liefs about health promotion, involvement in
health promotion activities, confidence in dealing
with behavior change, support for health promo-
tion activities, and optimism about chances for
success.

RESULTS

Characteristics of Respondents

Among the 87 respondents, 47 were located in
the community of Anderson and 40 were located
in the community of Florence. By specialty, 9%
were in general practice, 39% in family practice,
30% in internal medicine, and 22% in obstetrics/
gynecology. Ninety-eight percent were male. The
year of graduation from medical school ranged
from 1933 to 1984, with a mean of 1966. Fifty-
four percent of respondents graduated from med-
ical school in 1970 or later. There were no
differences between respondents and non-re-
spondents by community, by specialty, or by year
of graduation from medical school.

Beliefs about Health Promotion

Respondents were asked to indicate on a four-
point scale how important each of 23 health-
related behaviors was “in promoting the health of
the average person.” Table 1 shows the behaviors
that were considered “somewhat important” or
“very important” by 95% or more of respondents.

The Journal of the South Carolina Medical Association

HEALTH PROMOTION BELIEFS

While other health promoting behaviors (such as
alcohol moderation or elimination, decreasing salt
consumption, engaging in regular aerobic exer-
cise) received less emphasis, the overall picture is
that physicians recognize personal lifestyle behav-
iors as important to improving health status.

No significant differences were observed
among the four specialty groups. Only one health-
related behavior (avoiding excess calorie intake)
showed a significant difference among age
groups, as defined by year of graduation from
medical school. Older physicians (those graduated
before 1950) were less likely to stress the impor-

tance of reducing caloric intake.

Involvement in Health Promotion Activities
Physicians’ involvement in health promotion
was assessed by the extent to which they reported
“routinely” gathering information from patients
on smoking, alcohol, drugs, stress, exercise and
diet. Responses by specialty are summarized in
Table 2. Nearly all (90 percent) indicated that
they routinely gathered information in one or
more of the areas listed, but less than one-third (28
percent) reported that they routinely asked about
all of these behaviors. Four out of five physicians

TABLE I

Percentage of Physicians, by Specialty, Perceiving Health Promotion Behaviors as

Very Important

Behavior

or Somewhat Important to the Average Person

Family General Internal

Practice Practice Medicine Ob-Gyn

Total

n = 8

n = 26

n= 19

n = 87

Eliminate cigarette smoking

100%

Eat a balanced diet

100%

Avoid excess calorie intake

100%

92%

100%

98%

Avoid foods high in saturated fats

100%

96%

95%

98%

Always use a seatbelt when in a car

97%

100%

96%

100%

98%

Avoid foods high in cholesterol

100%

96%

89%

97%

Avoid undue stress

100%

88%

96%

89%

95%

Note: Complete information on other health promotion behaviors is available from the authors upon
request.

TABLE 2

Percentage of Physicians, by Specialty, Reporting Routinely Gathering
Information about Health-Risk Behaviors

Behavior

Family

Practice

General

Practice

Internal

Medicine

Ob-Gyn

Total

Smoking

76%

75%

92%

74%

80%

Alcohol0

62%

38%

88%

58%

67%

Other drugs

71%

50%

77%

53%

67%

Diet

35%

25%

62%

42%

44%

Exercise0 °

35%

38%

77%

32%

47%

Stress0 °

29%

25%

69%

26%

40%

Chi-squares for differences

among the specialties:

°p<0.05,

oop<0.01.

February 1989

HEALTH PROMOTION BELIEFS

routinely ask patients about smoking, two out of
three routinely ask about alcohol and other drugs,
while less than half routinely gather information
about diet, exercise, or stress.

There were significant differences among spe-
cialties with respect to the types of behaviors
about which they routinely ask patients. General
practitioners were less likely than other physicians
to report that they routinely gathered information
about alcohol, and internists were more likely to
ask patients about exercise or stress.

Confidence in Dealing with Behavior Change

Physicians’ confidence in their ability to help
patients change their behavior was determined by
self-reported assessment of preparedness for and
success in patient counselling. For each of the six
areas of interest (smoking, alcohol, drugs, diet,
exercise, stress), physicians were asked to indicate
the extent to which they felt prepared to counsel
patients and the extent to which they believed
they were successful in helping patients achieve
behavior changes.

As shown in Table 3, physicians varied some-
what in the extent to which they thought they
were prepared to counsel patients on different risk
factors. They were most likely to report feeling
prepared to counsel patients about smoking and
alcohol use, and least likely to report feeling pre-
pared to counsel about stress. In assessing their
current success in helping patients change behav-
ior, physicians expressed considerable less confi-
dence. From 48 to 68 percent reported success in
helping patients change behavior. However, only
six to eight percent thought they were “very suc-
cessful,” while most (45 to 59 percent) thought

they were “somewhat successful” in one or more
areas. Physicians were most likely to report suc-
cess in motivating patients to exercise and least
likely to report success in changing alcohol use.
There were no statistically significant differences
by type of specialty or year of graduation from
medical school for either physicians’ preparation
or current success in counselling.

Physicians were asked how successful they
thought they could be in helping patients change
behavior if given appropriate support. As com-
pared to the proportions who described them-
selves as currently successful, a considerably
higher proportion were optimistic about their po-
tential for success in helping patients exercise,
stop smoking, manage stress, modify diet, modify
drinking habits, and modify drug use. There were
no significant differences by type of specialty or
year of graduation from medical school.

Support for Health Promotion Activities

Most physicians (85 percent) reported that they
personally provided patient education rather than
relying on a nurse or other health professional.
When asked to indicate what different types of
assistance might be valuable to them in working
with patients, physicians most often specified in-
formation for patient referral and literature for
patients (Table 4). Videotapes for use with pa-
tients were least likely to be reported as valuable.

Physicians were also asked about the likelihood
of attending continuing medical education pro-
grams to strengthen their skills in changing behav-
iors related to risk factors. Over half of respon-
dents indicated that they would be likely to attend
an appropriate course. Topics preferred were as

TABLE 3

Percentage of Physicians Expressing Confidence in Dealing with Behavior Change in Patients

Behavior

Prepared to
Counsel Patients

Currently Successful
in Helping Patients

Potentially
Successful if
Given Support

Smoking

92%

59%

78%

Alcohol

90%

48%

76%

Other Drugs

80%

52%

70%

Diet

84%

57%

76%

Exercise

89%

68%

82%

Stress

74%

51%

78%

The Journal of the South Carolina Medical Association

HEALTH PROMOTION BELIEFS

TABLE 4

Percentage of Physicians Reporting Types of Assistance as

T ype of Assistance

Valuable

Valuable to Physician

Information for patient referral

85%

Literature for patients

84%

Risk factor questionnaires for patients

77%

Risk factor training for physicians

77%

Behavior modification training for physicians

77%

Reimbursement for physician time

76%

Training for support staff

72%

Reimbursement for staff time

63%

Videotapes for patients

61%

follows: stress reduction (67%), diet and nutrition
(63%), behavior modification (60%), alcoholism
and alcohol abuse (59%), exercise and physical
fitness (55%), smoking cessation (55%) and drug
abuse (55%).

DISCUSSION

Most physicians agreed that health promoting
behaviors are important to the average person,
although there were varying levels of agreement
on different risk behaviors. This finding is consis-
tent with previous studies5’ 6 and emphasizes the
need for consensus-building among medical pro-
fessionals to reduce conflicting public perceptions
of the relative importance of various health be-
haviors. This should involve demonstrating the
effectiveness of different prevention strategies,
ensuring the scientific validity of health promo-
tion beliefs, and providing public and professional
education. Not only do physicians believe that
health promotion is important, a substantial pro-
portion are involved in health-promoting ac-
tivities in their daily practice. Reported levels of
success in changing patient behavior are not very
high, but physicians did express considerable in-
terest in building their health promotion skills. In
addition, physicians expressed a high level of opti-
mism about their chances of helping patients to
make behavior change — if provided appropriate
support.

More efforts are needed to assist the physician
in fulfilling his/her role in health promotion. Con-
tinuing medical education courses are needed to
increase consensus in the medical community
about the relative importance of health promot-
ing behaviors, to increase physicians’ abilities to

help patients change their health-risk behaviors,
and to provide physicians with information about
available support services, including educational
materials, community resources, and allied health
personnel. Physicians do believe in the impor-
tance of health promotion, and given appropriate
support — including financial incentives for prac-
ticing preventive medicine — they can become
more effective in assisting patients to alter un-
healthy habits. □

ACKNOWLEDGEMENTS

The authors would like to thank Dr. Henry Wechsler for
permission to use the survey instrument, Drs. Carol Macera,
Jeff Jones and Clark Heath for manuscript review and critique,
and Marge Cooley and Linda Bennett for excellent secretarial
support. This work was supported in part by Cooperative
Agreement Number U50/CCU402234 from the Centers for
Disease Control.

REFERENCES

1. Healthy People: The Surgeon General’s Report on Health
Promotion and Disease Prevention. Washington, D.C.
Government Printing Office, 1979. DHEW Publication
No. (PHS) 79-55071.

2. Schoenborn CA: Health habits of U.S. adults, 1985: The
“Alameda 7” revisited. Public Health Reports 101: 571-580
1986.

3. Schoenborn CA, and Stephens T: Health promotion in the
United States and Canada: smoking, exercise, and other
health-related behaviors. American Journal of Public
Health 78: 983-984 1988.

4. Weinberg A, and Andrus PL: Continuing medical educa-
tion: does it address prevention? Journal Community
Health 7: 211-214 1982.

5. Wechsler H, Levine S, Idelson RK, Rohman M, and Taylor
JO: The physician’s role in health promotion — a survey of
primary care practitioners. New England Journal of Medi-
cine 308: 97-100 1983.

6. Valente CM, Sobal J, Muncie HL, Levine DM, and Antlitz
AM: Health promotion: physician’s beliefs, attitudes, and
practices. American Journal of Preventive Medicine 2:
82-88 1986.

February 1989

BELIEFS, ATTITUDES, AND HEALTH PROMOTION

In this issue, Wheeler and colleagues describe
the health promotion beliefs and attitudes identi-
fied by a survey of 87 physicians in two South
Carolina communities. Most (85%) of the physi-
cians reported that they personally provided in-
formation about healthy lifestyles rather than
delegating this task to office personnel. Four out
of five routinely asked their patients about smok-
ing; two out of three routinely asked about use of
alcohol and other drugs, while fewer than one-
half routinely inquired about diet, exercise, or
stress. Although most of the respondents consid-
ered themselves to be “somewhat successful” at
modifying patients’ behavior, fewer than one in
ten considered themselves to be “very successful. ”
Most indicated a need for continuing education
courses designed specifically to improve their
health promotion skills.

Promoting healthy lifestyles has long ranked
among the top priorities of the South Carolina
Medical Association. As to the level of our activity
in this area, we need make no apologies. Health
promotion has frequently dominated the ad-
dresses at our meetings, the content of our semi-
nars, and our priorities before the Legislature.
The Health Van is a new concept but not a new
point of emphasis. If these comments seem a bit
defensive, it is by design rather than accident. The
paper by Wheeler and colleagues adds to a large
body of literature addressing the beliefs and at-
titudes of physicians toward health promotion. At
times, not all of the conclusions seem entirely
realistic.

Consider smoking, for example. Surveys among
physicians have clearly identified elimination of
smoking as the single most important health be-
havior needing their attention.1 No argument. Yet
I take umbrage to a conclusion in the prestigious
American Journal of Medicine that “physicians
should provide advice about smoking as a regular
part of every patient visit.” (italics mine).2 While
such a conclusion aptly applies to the annual
physical examination, it seems entirely unrealistic

to expect busy physicians to initiate open-ended
conversations about smoking while, say, sewing
up lacerations or administering cancer chem-
otherapy. Everything in its proper time! Most
patients would, I suspect, agree. Surveys of pa-
tients indicate that they place more priority on
receiving appropriate treatment without delay
than on some of the things that health educators
like to talk about, such as continuity of care and
promotion of wellness.3

There are two issues: (1) what should we do? (2)
how should we do it? A reasonable assessment of
what health promotion desiderata can be readily
accomplished was provided by a questionnaire
given to third-year medical students.4 The stu-
dents expressed high confidence in the ability of
physicians to provide health screening physical
examinations, blood pressure control, cancer de-
tection education, family planning, health coun-
seling and education, immunizations, and sexual-
ly transmitted disease prevention. However, the
students expressed low confidence in the ability of
physicians to promote smoking cessation, nutri-
tion counseling and education, and weight reduc-
tion. Other surveys indicate that many physicians
are ill-equipped to deal with alcoholism,5 sexual
preference,6'7 and family matters.8 Hence, the
observation by Wheeler and colleagues that South
Carolina physicians were often unsure of their
abilities to have a positive impact on such things as
smoking, substance abuse, and stress management
is hardly surprising.

As to the second issue, how we should do it, it
must be appreciated that there is an important
stumbling block: the lack of adequate reimburse-
ment mechanisms. Adequate counseling takes
time. Most payment schemes provide little or no
allowance for physicians’ time given to counseling
on such matters as smoking cessation and stress
management. If health promotion is to be more
than the rendering of gratuitous advice, then
there must either be adequate reimbursement
mechanisms or alternative strategies to one-on-

The Journal of the South Carolina Medical Association

one counseling by physicians.

One strategy is to delegate such counseling to
office personnel. A recent survey in Texas indi-
cated that physician assistants are quite willing to
undertake a wider role in health promotion al-
though they, too, are uncertain about their abili-
ties to influence such things as smoking, drinking,
and use of illicit drugs.9 Another strategy is to
organize “wellness programs.” Adequate models
exist by which physicians can assume leadership
in promoting wellness throughout their commu-
nities.10 It is unrealistic to expect that advice given
during an annual physical examination will be
heeded throughout the year without reinforce-
ment. It is therefore appropriate that such well-
ness programs require time commitments by
patients as well as by physicians.

That most of the physicians surveyed by
Wheeler and colleagues were eager to improve
their health promotion skills is encouraging. What
is needed from educators are more clear-cut dem-
onstrations that our attempts to influence behav-
iors are indeed successful. Physicians, like most
people, are more willing to devote time and en-
ergy to those projects that have a reasonable pos-
sibility of success.11 Educators should convince us
of the effectiveness of new techniques, just as we
explore new ways by which to continue our lead-

ership in promoting health throughout our com-
munities.

1. Sobal J, Valente CM, Muncie HL Jr, et al: Physicians’
beliefs about the importance of 25 health promoting be-
haviors. Am J Public Health 75: 1427-1428, 1985.

2. Eraker SA, Becker MH, Strecher VJ, et al: Smoking behav-
ior, cessation techniques, and the health decision model.
Am J Med 78: 817-825, 1985.

3. Hagman E, Rehnstrom T: Priorities in primary health
care. The views of patients, politicians, and health care
professionals. Scand J Prim Health Care 3: 197-200, 1985.

4. Scott CS, Neighbor WE: Preventive care attitudes of med-
ical students. Soc Sci Med 21: 299-305, 1985.

5. Confusione M, Leonard K, Jaffe A: Alcoholism training in
a family practice residency. J Subst Abuse Treat 5: 19-22,
1988.

6. Smith EM, Johnson SR, Guenther SM: Health care at-
titudes and experiences during gynecologic care among
lesbians and bisexuals. Am J Public Health 75: 1085, 1985.

7. Douglas CJ, Kalman CM, Kalman TP: Homophobia
among physicians and nurses: an empirical study. Hosp
Community Psychiatry 36: 1309-1311, 1985.

8. Crouch MA, McCauley J: Family awareness demonstrated
by family practice residents: physician behavior and pa-
tient opinions. J Fam Pract 20: 281, 1985.

9. Fasser CE, Mullen PD, Holcomb JD: Health beliefs and
behaviors of physician assistants in Texas: implications for
practice and education. Am J Prev Med 4: 208-215, 1988.

10. Weaver RAR: “An ounce of prevention ...” How one
community wellness program has succeeded. J Med Assoc
Georgia 74: 320-321, 1985.

11. Radovsky L, Barry PP: Tobacco advertisements in physi-
cians’ offices: a pilot study of physician attitudes. Am J
Public Health 78: 174-175, 1988. ’

February 1989

SLOW POISONS

More than a century has passed since Oliver
Wendell Holmes wrote of his firm belief that “if
the whole material medica . . . could be sunk to
the bottom of the sea, it would be all the better for
mankind, and all the worse for the fishes.” That
Holmes’ opinion no longer holds true is no better
exemplified than in the case of drugs for the
treatment of hypertension. Still, side-effects con-
tinue to be the major stumbling block to successful
use of these drugs. In this issue, Drs. Lee and
Denton describe a newly-recognized, insidious
side-effect of anti-hypertensive therapy: chronic
hepatitis and indolent cirrhosis due to methyldopa
(Aldomet).

Methyldopa has long been associated with
acute hepatitis. Ordinarily, the symptoms of acute
hepatitis bring patients to medical attention and
thereby prompt discontinuation of the drug. Five
of the six patients described by Drs. Lee and
Denton had no history suggestive of liver toxicity,
yet showed evidence of cirrhosis at presentation.
While the authors acknowledge that the evidence
of methyldopa liver injury is largely circumstan-
tial, they make a cogent argument that serum
aspartate aminotransferase levels (AST; alter-
natively, SGOT) ought to be measured peri-
odically in patients taking methyldopa. They
conclude that asymptomatic, indolent liver injury
“may be the most common form of liver injury
seen due to this agent in the 1980’s.”

Reflecting on this timely report, I find three
reminders. First, we should remember that drugs
producing an acute side-effect on one or another
organ can also cause chronic damage, if con-
tinued. For example, nitrofurantoin (Macrodan-
tin) can not only cause an acute, symptomatic
pulmonary reaction sometimes with effusion but
can also cause insidious pulmonary fibrosis; phe-
nytoin (Dilantin) can not only cause acute ataxia
but can also cause permanent damage to the cere-
bellum with Purkinje cell loss. Second, we should
remember the potential for unexpected drug in-
teractions. Lee and Denton observed that all six of
their patients were receiving hydrochlorothiazide
along with methyldopa — either separately or as
part of the combination agent (Aldoril). Anec-
dotally, hydrochlorothiazide seems to be associ-
ated with other drug reactions, such as azotemia
related to tetracycline and widespread vasculitis
related to allopurinal (Zyloprim).

Finally, it pays to be ever-cognizant of what
drugs patients are receiving, and to think genet-
ically. Only by thinking of drugs by their generic
(as opposed to trade) names can we appreciate the
full impact of reports such as that by Drs. Lee and
Denton — and thus ask ourselves whether our next
patient might in fact manifest such an indolent
form of drug toxicity.

— CSB

The Journal of the South Carolina Medical Association

ON THE COVER:
GENTIAN A CATESBEI

The lovely blue gentian featured on this
month’s cover was named by Thomas Walter and
Stephen Elliott, both South Carolina botanists, in
honor of Mark Catesby, a British naturalist who
first described it in the 18th century while on an
excursion to the southern states. It is indigenous to
the grassy swamps of North and South Carolina,
where it flowers from September to December.

Jacob Bigelow, M.D., in his three volume work
on American Medical Botany, published in
Boston in 1818, says of the blue gentian, also
known as Sampson’s Snake Root:

I have found the root of this plant . . . invigo-
rates the stomach and gives relief in com-
plaints arising from indigestion. Dr. [James]
Macbride, at whose suggestion I first em-
ployed it, entertained a high opinion of its
tonic power in the cases of debility of the
stomach and digestive organs.

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In Mr. Elliott’s Botany of the Southern
States, we are told that . . .
it is used with decided advantage in cases of
pneumonia, where the fever is nervous, and
that it acts as a tonic and sudorific. ... It is
said' to increase the appetite, prevent the
acidification of the food, and to enable the
stomach to bear and digest articles of diet,
which before produced oppression and de-
jection of spirits.

Bigelow’s Botany from which the cover pho-
tograph comes is of interest as the first American
book with plates printed in color. When the pro-
cess of handcoloring the plates became too slow
and too expensive, Bigelow introduced a method
of printing in color. The last fifty plates of this
work are done by this method.

— Betty Newsom

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Fact is, more Americans may die by the fork than by any other weapon. That’s
because so many of them use it irresponsibly. Like to fill up on high-fat, high-
cholesterol foods. Foods that can load the blood with cholesterol, which can build
up plaque in their arteries, increasing their risk of heart attacks and threatening
their lives. So next time you pick up a fork, re-
member to handle it as you would any other American Heart

weapon. For self-defense, not self-destruction. Association

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This space provided as a public service.

The Journal of the South Carolina Medical Association

SOUTH CAROLINA MEDICAL ASSOCIATION

AUXILIARY

SCMA AUXILIARY REGIONAL VICE PRESIDENTS

The SCMA Auxiliary’s image of service is based upon the teamwork of an annual membership of over
1,600 physicians’ spouses across our state. Their common bond flows from the concerns they share for the
health and well-being of their medical families and the community as a whole. A year filled with
informative meetings, beneficial service projects and relaxing socials help to cement friendships and
increase membership.

The four Regional Vice Presidents of the SCMA Auxiliary — Central: Mrs. John M. Little, Jr.; Eastern:
Mrs. William Hester; Southern: Mrs. Randolph D. Smoak, Jr.; Western: Mrs. C. Wayne Fisgus — serve as
liaisons between the state Board and county Auxiliaries. Utilizing newsletters, telephone calls, personal
notes and visits, they have maintained contact with the organized counties. Serving as communications
links, they offer support and information and address their challenges with enthusiasm. This, in turn, has
developed friendships, rapport and a sharing of ideas that have helped to achieve our Auxiliary goals. The
state Membership Committee has focused upon retaining, recruiting, and increasing membership. Their
campaign has been very successful this year with membership already at 1,460 as of mid-January.

While efforts to improve community health remain a primary goal for our members, the changing
social environment has heightened efforts to respond to our own medical family concerns as well. The
support services (medical malpractice support groups being just one of many) are encouraged and
provided by auxilians for the special stresses of medical family life.

When the Auxiliary mounts a campaign to fight child abuse or substance abuse or to promote health
education, such as with the new van, it does so with the broad range of resources supplied by the physicians
of our state and county medical associations.

Another arm of the Auxiliary is in the legislative area. It is one of decisive support for organized
medicine’s effort to impact the issues that affect physicians and their ability to deliver quality patient care.
These legislative activities, such as a Day at the Capitol, serve to educate our auxiliary members on the
issues and the importance of being involved.

Continued financial support of medical students and schools through AMA-ERF and scholarships has
been accomplished through numerous innovative fund-raising projects. Auxiliary contributions nation-
wide to AMA-ERF have grown to nearly $2 million dollars to help support medical education at a time
when it desperately needs our help.

Our county and state Auxiliaries have a visible and viable voice that gives them the credibility to
articulate the concerns of their members in a variety of forums. From health promotion to legislative
efforts, the fact that it is connected in name and image to organized medicine makes the Medical Auxiliary
a force to be looked up to and recognized in the whole scope of its endeavors. Positive commitment to the
SCMA Auxiliary is high and we are looking forward to Convention and the completion of an exciting and
positive year.

Respectfully submitted,

Kathleen Class Fisgus (Mrs. C. Wayne)

February 1989

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Ridgeview Institute

Roche Laboratories

U. S. Air Force

U. S. Army Reserve

U. S. Navy

Winchester Surgical Supply Company

The Journal of the South Carolina Medical Association

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION
VOLUME 85 MARCH 1989 NUMBER 3

CLINICAL EXPERIENCE WITH CIPROFLOXACIN:
ANALYSIS OF A MULTI-PRACTICE STUDY*

C. P. DUNBAR, M.D.**

RONALD L. ASHTON, M.D.

LARRY ATKINSON, M.D.

HENRY F. CROTWELL, M.D.

HENRY M. FARIS, M.D.

HOWARD G. ROYAL, JR., M.D.
DUNCAN W. TYSON, M.D.
CHARLES H. WHITE, JR., M.D.

Ciprofloxacin (CIPRO) is a newly approved
(1987) antimicrobial which demonstrated high
activity in vitro against gram-negative and gram-
positive aerobic pathogens.1- 2 It has excellent in
vitro activity against Enterobacteriaceae species,
Pseudomonas aeruginosa, Haemophilus and
Neisseria species.3 Orally administered, ciproflox-
acin exhibits therapeutically achievable Minimal
Inhibitory Concentrations (MICs) against meth-
icillin-resistant Staphylococcus aureus and is the
most potent oral antimicrobial available for use
against this pathogen.4 Therefore, ciprofloxacin
has been regarded as an excellent oral alternative
to injectable antibiotics.

Most of the literature reports double-blind, con-
trolled comparative trials intended for submission
to the FDA for marketing approval. However,
these studies contain extremely restrictive inclu-
sion and exclusion criteria and may or may not be

From practices and clinics in the following South Carolina
localities: Leesville (Dr. Gunter); Greenville (Drs. Ashton
and Faris); Anderson (Dr. Atkinson); York (Dr. Crotwell);
Aiken (Dr. Royal); Florence (Dr. Tyson); and Sumter (Dr.
White).

Address correspondence to Dr. Dunbar at B & L Family
Practice, 106 Gunter Street, Leesville, S. C. 29070.

related to how the product would perform in the
day-to-day practice of medicine. Thus, an evalua-
tion of the efficacy and safety of ciprofloxacin in
day-to-day medical practice was performed. In
the following, data from an open clinical multi-
practice study performed in the state of South
Carolina are reported.

PATIENTS AND METHODS

Guidelines for patients admitted into the study
were established by a standardized protocol. Data
were collected on brief, two-page Clinical Eval-
uation Forms (CEFs) completed by the investiga-
tors. Subsequently, the CEFs were retrieved and
analyzed by Oxford Health Care, Inc., Clifton,
New Jersey. Each physician investigator catego-
rized all patients’ infections as either lower respi-
ratory tract, soft tissue, skin and skin structure, or
other. Eight investigators from South Carolina
entered 113 patients into the study. Only those
patients who received ciprofloxacin alone as anti-
microbial therapy were evaluated.

Several criteria determined patient selection.
Inclusions: male and female inpatients or outpa-
tients over 18 years of age who exhibited clinical
evidence of lower respiratory tract infection, skin

March 1989

CIPROFLOXACIN

and skin structure infection, or soft tissue infec-
tion. Exclusions: females who were pregnant,
nursing, or not practicing contraception; patients
with known or suspected allergy to quinolone
antibiotics or with known moderately to severely
impaired renal function; those displaying clinical
evidence of hepatic disease or requiring other
concomitant antimicrobial therapy; and patients
with known clinically impaired immunological
function.

Physicians were asked to record adverse reac-
tions, their duration and intensity, and the action
taken in regard to medication adjustment or out-
come. Any serious or unexpected reaction was to
be reported within 72 hours to Miles, Inc. The
investigators were to use their judgment regard-
ing patient response to therapy and to adjust anti-
microbial medication if response was determined
inadequate. Patients were allowed to receive any
other medication deemed necessary by the physi-
cian. The package insert acted as the guideline for
prescribing information.

BACTERIOLOGY

Specimens were collected, when available,
from sites of suspected infection prior to the ad-
ministration of ciprofloxacin. Physicians were also
asked to obtain a culture at the end of ciproflox-
acin therapy if culturable material was available.
Sensitivity analysis was performed using cipro-
floxacin disks provided by Miles, Inc. For patients
with respiratory tract infections, sputum was pro-
cessed for gram stain and culture whenever possi-
ble. However, many lower respiratory tract
infections and closed wound infections precluded
collection of a culture specimen.

RESULTS

A biostatistician at Oxford Health Care, Inc.
supervised data processing. The statistics gener-
ated were descriptive in nature, tabulated exactly
from the CEF. Complete as well as incomplete
CEFs were included in the results, regardless of
whether or not the physician followed every pro-
tocol parameter. All patients were included in the
analysis of clinical efficacy, however only those
patients who had a positive culture with an identi-
fied organism were included in the evaluation of
bacteriologic efficacy.

No patient who received any type of anti-infec-
tive medication concomitantly with ciprofloxacin

was evaluable for either safety or efficacy. All 113
patients, with the exclusion of those who received
a concomitant antimicrobial, were included in the
analysis of tolerance to the drug and of adverse
effects of treatment. The data indicated that no
patient received a concomitant antibiotic in this
study. Skewed data were eliminated when nec-
essary.

A total of 113 patients (51 men and 55 women
reported) aged 15 to 92 years (mean age 40.2
years) received 0 to 1500 mg of ciprofloxacin per
day (mean dosage 995 mg per day) for 2 to 19 days
(mean duration, 9.6 days).

The spectrum of infections treated comprises a
variety that would be expected in a multicenter
trial with eight participating physicians from
across the state. For the total patient population,
the majority of infections were classified as lower
respiratory tract (34.6%), followed by soft tissue
(25.9%), skin and skin structure (19.2%), urinary
tract (7.7%) and other (12.5%). Of note, the major-
ity of patients treated, 95.1%, were outpatients;
hospitalized patients accounted for only 4.9%
treated. Four patients were continuing ciproflox-
acin therapy at the time of evaluation.

Patients were evaluated for both clinical and
bacteriologic efficacy. All patients who received
one dose of ciprofloxacin were considered for the
evaluation of the clinical efficacy of therapy, re-
gardless of whether or not a culture was obtaina-
ble. Physicians were asked to rate the final clinical
outcome of the infection by indicating cure, im-
provement or failure. Final clinical outcome of
therapy with ciprofloxacin for each diagnostic
category is summarized in Table 1. Clinical cure
was achieved in 74%, improvement in 23.1% of
cases. Overall clinical cure plus improvement
equaled 97.1% of treated infections. Only three
patients (2.9%) had outcomes considered clinical
failures by the treating physician.

Patients who had an initial culture that identi-
fied a pathogen were included in the analysis of
bacteriologic efficacy. Positive cultures were ob-
tained in 17 patients initially. Of these, in 14 cases
the bacteria cultured and the outcome of therapy
was specified. Negative cultures and cultures in-
dicating normal flora were not evaluable. Within
these parameters, for 14 of 113 patients the infec-
tion was microbiologically proven. Of the evalua-
ble patients, bacteriologic cure equaled 42.9%,
while improvement comprised 50%. Cure plus

The Journal of the South Carolina Medical Association

CIPROFLOXACIN

TABLE 1

Final Clinical Outcome Classified by Location of Infection"

% of total (No. of pts.)

Cure i?

Cure

Improv

Failure

Improv

Lower respirator}- tract

61.1% (22)

36.1% (13)

2.8% (1)

97.2%

Soft tissue

88.9% (24)

11.1% (3)

0% (0)

100%

Skin/skin structure

80.0% (16)

10% (2)

90%

Urinary tract

87.5% (7)

12.5% (1)

0% (0)

100%

Other

61.5% (8)

38.5% (5)

0% (0)

100%

Total

74%

23.1%

2.9%

97.1%

°Data unavailable for 9 patients.

improvement was 92.9%. Failure was reported in
only 7.1% of cases.

The 14 positive cultures identified 16 orga-
nisms. These organisms were distributed across
the diagnostic categories in the following manner:
the majority of infections were classified as lower
respiratory tract (87.5%), followed by skin and
skin structure (12.5%). The soft tissue, urinary-
tract and other categories had no bacteriologically
proven cases. Though urinary tract infection was
not a category on the CEF, it was statistically
separated for discussion and analysis. The nine
reported pathogens and their bacteriologic out-
come are summarized in Table 2.

Overall, seventeen (16.7%) infections were con-
sidered chronic. Both the final clinical and bac-
teriologic outcomes were indicated for the
chronic infections. For eight patients, data were
available as to the final clinical outcome. Two
patients were cured and six improved. x\ddi-
tionallv, for seven patients, information was avail-
able as to bacteriologic outcome. Two patients
were cured and five improved. No failures were
reported for chronic infections in either category.

ADVERSE REACTIONS

All 113 patients treated with ciprofloxacin were
included in the evaluation of tolerance and ad-

TABLE 2

Nine Pathogens Identified in 14
Evaluable Cultures and Bacteriologic Outcome

Type of Organism

Cure

Outcome

Improv

Fail

Pseudomonas species

Haemophilus influenzae

Staphylococcus species

Streptococcus pneumoniae

Staphylococcus epidermidis

Neisseria species

Klebsiella species

Streptococcus species

Streptococcus pyogenes

March 1989

CIPROFLOXACIN

verse effects related to therapy. Of the 113 pa-
tients, 108 reported no side effects (95.5%). Five
reports of ADRs were observed; one case of de-
pression, two cases of nausea, and two rashes.
Gastrointestinal (GI) symptoms comprised two
(40%) ADRs. Only one ADR, a case of nausea, was
considered definitely drug related. The other
ADRs were considered either definitely not re-
lated, or uncertainly related to therapy. Cipro-
floxacin therapy was maintained in two cases and
discontinued in three. Only three patients (2.6%)
discontinued treatment because of adverse reac-
tions; one patient had rash, the other two had
nausea. No abnormal laboratory findings were
reported, nor were any reports of crystalluria
found.

DISCUSSION

A relatively new class of antimicrobials, the
fluoroquinolones, has emerged as a powerful new
resource for physicians to treat a broad spectrum
of infections. Ciprofloxacin is a potent member of
this drug classification.

Analysis of this multicenter study indicates that
there is a good correspondence between the in
vitro activity of ciprofloxacin and the clinical
efficacy of treatment with ciprofloxacin. Clinical
cure was observed in 74% of all infections. Cure
plus improvement equaled 97.1% of all cases.

Bacteriologic efficacy (cure plus improvement)
equaled 92.9%, while clinical efficacy was 97.1%.
Interestingly, bacteriologic efficacy was almost
the same as clinical efficacy, though not quite as
high. For eight chronic infections with a known
clinical outcome, two were cured and six im-
proved. For seven infections the known bac-
teriologic outcome was almost identical to clinical
outcome; two were cured and five improved.
Chronic, as well as acute, infections responded
extremely well to ciprofloxacin therapy.

The safety of ciprofloxacin was assessed for all
patients. Overall, therapy with ciprofloxacin was
extremely well tolerated. Adverse experiences
were infrequent and generally mild. Treatment
with ciprofloxacin had to be discontinued for only
three patients (2.6%) because of adverse expe-
riences.

Furthermore, physicians reported 15 classifica-
tions of medications that were administered con-
comitantly with ciprofloxacin. Bronchodilators,
theophylline, cardiotonics, and diuretics headed

100

the list. Still, adverse reactions were minimal. No
patients were reported to have had an allergic
reaction to ciprofloxacin, nor were any incidents
of theophylline toxicity reported.

CONCLUSION

The isolation of etiologic bacteria is difficult,
especially in infections of the lower respiratory-
tract and in closed wound infections. Clinical
results reported here include cases with and with-
out obtained culture and sensitivity results. Bac-
teriologic efficacy was determined by culture and
sensitivity. The main purpose of the study was to
gather a large amount of safety and efficacy data
on ciprofloxacin, after its FDA approval, as used
in a day to day clinical setting in order to confirm
the results in smaller, more restrictive trials used
for FDA approval of the product.

The present clinical experience has shown that
a dosage of 500 to 1500 mg of ciprofloxacin ther-
apy per day is effective in a broad spectrum of
infections including E. coli, Staphylococcus au-
reus, Proteus species, Streptococcus species, in-
cluding S. pneumoniae, Pseudomonas species and
Staphylococcus epidermidis. In addition to an
overall clinical efficacy (cure plus improvement)
of 97.1%, the bacteriologic efficacy in patients
was 92.9%.

Furthermore, the safety of ciprofloxacin was
excellent. Adverse reactions were generally mild,
gastrointestinal in nature and infrequent. In con-
clusion, it appears that ciprofloxacin offers ease of
administration as well as high efficacy and safety
in the treatment of a wide variety of infections
that might well have previously required paren-
teral therapy and/or hospitalization.

SUMMARY

In a multi-practice study of 113 patients treated
with ciprofloxacin (mean daily dosage, 995 mg
per day; mean duration of treatment, 9.6 days) for
a variety of infections, 14 were microbiologically
proven. Of these, bacteriologic cure and/or im-
provement resulted in 92.9% of cases. For all 113
infections, clinical cure and/or improvement re-
sulted in 97.1% of cases. A total of 17 infections
were classified as chronic. Therapy with cipro-
floxacin was discontinued in three (2.6%) of 113
patients because of adverse effects. Overall, there
were 5/113 (4.4%) adverse reactions (ADRs).
Only one ADR was related definitely to ciproflox-

The Journal of the South Carolina Medical Association

acin therapy. Two ADRs were definitely not re-
lated; in two the relationship was uncertain. Two
patients of the five (40%) elected to continue
ciprofloxacin therapy despite mild side effects. □

REFERENCES

1. Sanders CC. Sanders WE, Jr.. Goering RV. Overview of
preclinieal studies with ciprofloxacin. Am J Med 1987:
82:Suppl 4A:2-11.

2. Barry AL. Jones R\. In vitro activity of ciprofloxacin
against gram-positive cocci. Am J Med 1987: 82:Suppl
4A:27-32.

3. Lyon MD. Smith KR. Saag MS, Cobbs CG. Brief report: in
vitro activity of ciprofloxacin against Neisseria gonor-
rhoeae. Am J Med 1987; 82:Suppl 4A:40-1.

4. Data on file. Miles. Inc., Pharmaceutical Division.

Your Local MDX Dealer is:

the G Geisler Group, Inc.

91 1 Lyttleton Street
Camden, SC 29020

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March 1989

101

Consider the
causative organisms...

cefaclor

250-mg Pulvules t.i.d.
offers effectiveness against
the major causes of bacterial bronchitis

Haemophilus influenzae and Streptococcus pneumoniae

(ampicillin-susceptible and ampicillin-resistant)

Note: Ceclor is contraindicated in patients with known allergy Penicillin is the usual drug of choice in the treatment and
to the cephalosporins and should be given cautiously to prevention of streptococcal infections, including the prophy-
penicillin-allergic patients. laxis of rheumatic fever. See prescribing information.

Ceclor® (cefaclor)

Summary. Consult the package literature for
prescribing information.

Indication: Lower respiratory infections,
including pneumonia, caused by Streptococcus
pneumoniae, Haemophilus influenzae, and
Streptococcus pyogenes (group A /3 -hemolytic
streptococci).

Contraindication:

Known allergy to cephalosporins.

Warnings:

CECLOR SHOULD BE ADMINISTERED CAUTIOUSLY TO
PENICILLIN-SENSITIVE PATIENTS. PENICILLINS AND CEPHA-
LOSPORINS SHOW PARTIAL CROSS-ALLERGENICITY. POSSI-
BLE REACTIONS INCLUDE ANAPHYLAXIS.

Administer cautiously to allergic patients.
Pseudomembranous colitis has been
reported with virtually all broad-spectrum anti-
biotics. It must be considered in differential
diagnosis of antibiotic-associated diarrhea.
Colon flora is altered by broad-spectrum
antibiotic treatment, possibly resulting in
antibiotic-associated colitis.

Precautions:

• Discontinue Ceclor in the event of allergic
reactions to it.

• Prolonged use may result in overgrowth of
nonsusceptible organisms.

• Positive direct Coombs' tests have been re-
ported during treatment with cephalosporins.

• Ceclor should be administered with caution in
the presence of markedly impaired renal func-
tion. Although dosage adjustments in moderate
to severe renal impairment are usually not
required, careful clinical observation and labo-
ratory studies should be made.

• Broad-spectrum antibiotics should be pre-
scribed with caution in individuals with a his-
tory of gastrointestinal disease, particularly
colitis.

• Safety and effectiveness have not been deter-
mined in pregnancy, lactation, and infants less
than one month old. Ceclor penetrates mother's
milk. Exercise caution in prescribing for these
patients.

Adverse Reactions: (percentage of patients)
Therapy-related adverse reactions are
uncommon. Those reported include:

• Gastrointestinal (mostly diarrhea): 2.5%.

• Symptoms of pseudomembranous colitis may
appear either during or after antibiotic treat-
ment.

• Hypersensitivity reactions (including mor-
billiform eruptions, pruritus, urticaria, and
serum-sickness-like reactions that have
included erythema multiforme [rarely, Ste-
vens-Johnson syndrome] or the above skin
manifestations accompanied by arthritis/
arthralgia and, frequently, fever): 1 .5%; usually
subside within a few days after cessation of
therapy. Serum-sickness-like reactions have
been reported more frequently in children than
in adults and have usually occurred during or
following a second course of therapy with
Ceclor. No serious sequelae have been
reported. Antihistamines and corticosteroids
appear to enhance resolution of the syndrome.

• Cases of anaphylaxis have been reported, half
of which have occurred in patients with a his-
tory of penicillin allergy.

• As with some penicillins and some other
cephalosporins, transient hepatitis and chole-
static jaundice have been reported rarely.

• Rarely, reversible hyperactivity, nerv-

ousness, insomnia, confusion, hypertonia
dizziness, and somnolence have been reported

• Other: eosinophilia, 2%; genital pruritus or
vaginitis, less than 1%: and, rarely, throm-
bocytopenia.

Abnormalities in laboratory results of uncertain
etiology

• Slight elevations in hepatic enzymes.

• Transient fluctuations in leukocyte count
(especially in infants and children).

• Abnormal urinalysis: elevations in BUN or
serum creatinine.

• Positive direct Coombs' test.

• False-positive tests for urinary glucose with
Benedict's or Fehling's solution and Clmitest”
tablets but not with Tes-Tape® (glucose
enzymatic test strip, Lilly).

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Carolina, Puerto Rico 00630

SEROPREVALENCE OF HUMAN
IMMUNODEFICIENCY VIRUS IN
MENTAL HEALTH PATIENTS*

WALTER K. CLAIR, M.D.**
G. PAUL ELEAZER, M.D.
LINDA JEAN HAZLETT, B.A.
B. ANN MORALES, B.A.
JUDITH M. SERCY, B.S.

LEE V. WOODBURY, M.D.

There have been numerous reports on the prev-
alance of human immunodeficiency virus (HIV)
infection among parenteral drug abusers. 1-3 How-
ever, we were able to find few published reports
on the prevalence of HIV infection among pris-
oners3'7 and none on psychiatric inpatients.

These three populations (parenteral drug
abusers, prisoners, and psychiatric inpatients)
have always been a challenge to personal and
public health care providers because of the com-
plicated legal and ethical issues surrounding their
care. The parenteral drug abuse population is a
major reservoir from which HIV infection is
spread to the heterosexual population. And while
they have been granted little attention, prisons
and inpatient psychiatric institutions, rather than
being sanctuaries from the HIV epidemic, may
become additional reservoirs of infection.

Because our hospital serves each of these popu-
lations, we undertook a study to assess the
seroprevalence of HIV infection among our pa-
tients. Our hope was to use this and other informa-
tion to help establish rational policies and proce-
dures based on reasonable estimates of HIV
seropositivity in our institution rather than
through extrapolation from data derived from
other settings.

From January 18, 1988 through February 29,
1988, we did HIV serological tests on the sera of
1,530 patients. The testing was done anonymously

° From the Byrnes Medical Center, Columbia, S. C.
Address correspondence to Walter K. Clair, M.D., C. M.
Tucker Human Resources Center, 2200 Harden Street,
Columbia, S. C. 29203.

on the residual sera of blood that had been sent for
blood chemistries.

METHODS

Hospital Description

James F. Byrnes Medical Center is a 166 bed
facility that provides acute medical-surgical care
and laboratory testing for inpatients of the various
facilities of the South Carolina Department of
Mental Health. These patients include inmates
from the S. C. Department of Corrections (Cor-
rections), those involuntarily committed to the
Chemical Dependence Detoxification Program
(Detox), and the general patient pool of the S. C.
Department of Mental Health (DMH).

Design

Our research proposal was approved by the
S. C. Department of Mental Health Institutional
Review Board and the S. C. Department of Cor-
rections, once we presented an acceptable pro-
tocol for assuring anonymity and minimizing
duplicate testing.

After performing the requested blood chem-
istries, our laboratory routinely stores residual sera
at four degrees centigrade for seven days. From
January 18, 1988 through February 29, 1988, each
serum sample that had at least 1.5 ml. of residuum
was assigned a numeric code which was recorded
on a data log sheet with the corresponding pa-
tient’s name, hospital number, date of birth, race,
sex, county of residence, and ward or referring
facility. Laboratory personnel gave these data log
sheets to data entry personnel who input this

March 1989

103

HIV SEROPREVALENCE

information into a computer using the program
dBASE III Plus (registered trademark Ashton-
Tate). The database was polled for each patient s
name as it was entered to check for name-based
duplicate records. If the name was already in the
study, the record was not entered and the corre-
sponding data were removed from the log sheet.

The edited log sheets were returned to labora-
tory personnel who forwarded the corresponding
sera to the laboratory of the S. C. Department of
Health and Environmental Control. There the
sera were subjected to enzyme-linked immu-
nosorbent assay (ELISA). Those sera that were
repeatedly reactive on ELISA testing were tested
by Western blot and designated positive if bands
p24 and gp41 were present. These serology results
were reported back to our staff in a manner such
that two data sets were maintained and managed
separately. One data set contained the patients’
names, demographic data and the numeric codes
of the corresponding sera. The other contained
numeric codes and serology results only.

Our hospital maintains logs of all patients it
knows to be HIV positive and of all patients on
whom HIV serological tests have been requested
through our laboratory. From these logs, we iden-
tified that subset of sera that was from patients
already known to be HIV positive or were pre-
sumably tested on the basis of clinical suspicion.
We labeled these combined groups “suspects.”

After testing 1,530 samples of residual sera, the
demographic data set was again checked for du-
plicates. This time we used the hospital number,
birth date and name to eliminate duplicates. If the
serum was from a patient on our log of “suspects,”
it was so noted in a field on the record. Having
minimized duplication, the name, hospital num-
ber, and county of residence were deleted from
each record. The demographic data set was then
merged with the data set containing numeric
codes and test results producing a single anony-
mous data set with information on 1,496 serum
samples.

RESULTS

Of 1,496 unduplicated samples, 36 were posi-
tive on ELISA testing. Eight (Table 1) were
seropositive by Western blot representing 0.53%
of those tested. All donors of Western blot positive
sera were male. Six were black, and only one was
older than 33.

The percentages of Western blot positives in

TABLE 1

Characteristics of Western Blot Positives

Service

Sex

Race

Age

Suspected

Corrections

Yes

Detox

Yes

Detox

Yes

DMH

Yes

DMH

Corrections indicates inmates from the S. C. Department of
Corrections; Detox, patients in the Chemical Detoxification
Program; DMH, the general patient pool of the S. C. Depart-
ment of Mental Health.

various subgroups are summarized in Table 2.
The prevalence of Western blot positivity was
greatest among Corrections Ward sera and those
grouped as suspected.

Table 3 depicts characteristics of the three ser-
vices of our hospital: inmates from the Depart-
ment of Corrections (Corrections), participants in
the Chemical Dependence Detoxification Pro-
gram (Detox Program), and general Department
of Mental Health patients (DMH). The trends
toward greater male, black, and youth predomi-
nance paralleled the significantly greater preva-
lence of HIV positive sera on the Corrections
Ward. This table further shows that patients were
most likely to be known HIV positives or to have
been previously tested through our laboratory if
they were on the Detoxification Ward.

One can see from Table 4 that all those suspects
who were ELISA positive were also positive by
Western blot. In contrast, only four of the 32
ELISA positives among the unsuspected were
confirmed to be seropositive by Western blot.

COMMENTS

This study was designed to provide us with data
useful in developing policies and procedures in
the three patient populations served by our facil-
ity: psychiatric inpatients, alcohol and drug abuse
patients, and prison inmates.

The 0.24% prevalance in psychiatric inpatients
(our largest referral group) was noteworthy be-
cause of the lack of published prevalence data on

104

The Journal of the South Carolina Medical Association

HIV SEROPRE VALENCE

this subgroup and the special management prob-
lems presented by these patients. The prevalence
we found in this group is remarkably comparable
to the 0.3% reported for the first 12.000 general
hospital patients tested by the Center for Disease
Control’s blinded surveys in sentinel hospitals.4
This would suggest that, at least at the present
time, there appears to be no increased risk of

TABLE 2

% (No.) Testing Western Blot Positive

Sex

Male

.84 (8/952)

Female

.00 (0/544)

Race

Black

.94 (6/639)

White

.24 (2/849)

Other

.00 (0/8)

Age

<35

1.11 (7/630)

.12 (1/866)

Service

Corrections

4.62 (3/65)

Detox

.99 (2/203)

DMH

.24 (3/1,228)

Suspected

Yes

4.49 (4/89)

.28 (4/1,407)

Total

.53 (8/1.496)

Corrections indicates inmates from the S. C. Department of
Corrections; Detox, patients in the Chemical Dependence
Detoxification Program; DMH. the general patient pool of the
S. C. Department of Mental Health.

Suspected

TABLE 4

vs. Unsuspected Test Results

% Positive (n )

Suspected Unsuspected

ELISA

4.5 (4/89)

2.27 (32/1.407)

Western

blot

4.5 (4/89)

.28 (4/1.407)

seropositivity among our psychiatric inpatients
when compared to general hospital admissions.

The prevalence rate among patients admitted
for chemical dependence was 0.99%. This rate
was somewhat lower than we expected. However,
since this ward consists largely of clients who are
alcohol dependent with a variable number of
parenteral drug abusers, this lower rate should not
be interpreted as the seroprevalence among par-
enteral drug abusers in our referral base. Our
study did not allow us to determine separate prev-
alence data for parenteral drug abusers.

In prison inmates admitted to our hospital, the
prevalence rate was 4.6% which is greater than the
2.9% prevalence rate reported for 29.193 inmates
tested by the Federal Bureau of Prisons.4 This
difference most likely reflects our small numbers
(3 65) and the referral nature of our population.
Thus, our data should not be extrapolated to the
general inmate population of South Carolina.
Nevertheless, this group had our highest rate of
seropositivity and is particularly noteworthy be-
cause the majority of admissions to this service are
for surgical procedures. Forty-five of the 85 in-
mates on the Corrections Ward during the study
period had an operative procedure.

In our study, serum was considered positive
only when it was both repeatedly positive on

TABLE 3

Service Characteristics

% Male

% Black

% <35

% HIV Pos.

% Susp.

Corrections (N = 65)

4.6

9.2

Detox (N = 203)

.99

16.3

DMH (N = 1,228)

.24

4.0

Corrections indicates inmates from the S. C. Department of Corrections: Detox, patients in the Chemical Dependence Detoxification
Program: DMH. the general patient pool of the S. C. Department of Mental Health.

March 1989

105

HIV SEROPREVALENCE

ELISA testing and confirmed by Western blot.
Our data affirm the use of the ELISA test as a
screening test rather than a diagnostic test. Had
we relied solely on repeatedly positive ELISA
tests, we would have inappropriately labeled 28
sera HIV positive. Because Western blots were
done only on those that were repeatedly ELISA
positive, we theoretically had an unknown num-
ber of false negatives. However, there is a consen-
sus of opinion that using the ELISA and Western
blot sequentially results in an insignificant num-
ber of false negatives.7- 8

Of the eight sera that tested Western blot
positive, half were from patients who were not
suspected of being HIV positive (Table 1). Two of
these unsuspected positives were on the Correc-
tions Ward and two were among the general
psychiatric patients. In contrast, both positive sera
from chemically dependent patients came from
patients who were suspected of being HIV
positive. Other studies have also demonstrated
that a significant number of HIV positive patients
go unsuspected and are only discovered through
anonymous testing programs.9- 10 These studies
and our own validate the use of universal precau-
tions in preference to "blood and body fluid pre-
cautions" labeling.

Our study is limited in that it is neither a
complete survey, nor is it a random sample. We
tested residual sera only from those who had
serum chemistries ordered during our study pe-
riod. Furthermore, not all of the samples had
enough residual serum for HIV testing. While we
do not believe our data can be generalized beyond
our facility, these data provide the framework for
continued surveillance in our three patient
groups. We would urge caution in extrapolating
our results to other regions of the country since the
prevalence of HIV seropositivity varies consider-
ably across the nation. However, psychiatric in-
stitutions in regions with reported AIDS case rates
comparable to those of South Carolina may find
this study useful. We urge that further studies be
done on psychiatric inpatients to provide a
broader database for policy makers.

SUMMARY

In contrast to the published data on Human
Immunodeficiency Virus (HIV) infection in par-

106

enteral drug abusers, there is a paucity of data on
prison inmates and virtually none on psychiatric
inpatients. Because our facility serves each of
these patient groups, we designed an anonymous
seroprevalance study. We tested 1,496 undupli-
cated sera using sequential enzyme-linked immu-
nosorbent assay (ELISA) and Western blot tests.
The overall prevalence of Western blot positive
serum was 0.53%. The prevalence rates for the
different services of our hospital, Corrections, De-
toxification Program, and general Department of
Mental Health inpatients, were 4.62%, 0.99%, and
0.25% respectively. While these data demonstrate
the increased prevalence of HIV infection among
prison inmates, they fail to show a greater preva-
lence among South Carolina psychiatric inpa-
tients than among general hospital patients. □

ACKNOWLEDGEMENTS

The authors wish to thank John R. Simmons, M.D.. Kim
Randolph, R.N., Lila H. Crouch and Danelle Rowe, CMT. for
their assistance with this study.

REFERENCES

1. Lange WR, Snyder FR, Lozovsky D. et al: Geographic
distribution of Human Immunodeficiency Virus markers
in parenteral drug abusers. Am J Public Health.
78:443-446, 1988.

2. Levy N, Carlson JR, Hinriehs, et al: The prevalence of
HTLVIII/LAV antibodies among intravenous drug users
attending treatment programs in California: A prelimi-
nary report. N Engl J Med, 314:446, 1986.

3. Human Immunodeficiency Virus infection in the United
States: A review of current knowledge. MMWR 36:5-6,

1987.

4. Quarterly report to the Domestic Policy Council on the
prevalence and rate of spread of HIV and AIDS in the
United States. MMWR 37:223-227, 1988.

5. Glass GE, Hausler WJ. et al: Seroprevalence of HIV anti-
bod)' among individuals entering the Iowa Prison System.
Am J Public Health 78:447-449, 1988.

6. Kelley PW, Redfield RR, Ward DL, et ah Prevalence and
incidence of HTLV-III infection in a prison. JAMA
256:2198-2199, 1986.

7. Schwartz JS, Dans PE and Kinosian BP: Human Immu-
nodeficiency Virus test evaluation, performance, and use:
Proposals to make good tests better. JAMA 259:2574-2579.

1988.

8. Francis DP and Chin J: The Prevention of Acquired
Immunodeficiency Syndrome in the United States: An
objective strategy for medicine, public health, business,
and the community. JAMA 257:1357-1366, 1987.

9. Baker JL, Kelen GD, et ah Unsuspected Human Immu-
nodeficiency Virus in critically ill emergence patients.
JAMA 257:2609-2611, 1987.

10. Fleming DW, Cochi SL, et ah Acquired Immunodefi-
ciency Syndrome in low-incidence areas: How safe is
unsafe sex? JAMA 258:785-787, 1987.

The Journal of the South Carolina Medical Association

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108

The Journal of the South Carolina Medical Association

LYMPHOMATOID PAPULOSIS: MOSTLY BENIGN
BUT POTENTIALLY MALIGNANT—

A CASE REPORT WITH A FATAL OUTCOME

LARRY H. PARROTT, M.D.*

Lymphomatoid Papulosis is usually a chronic
intermittent skin eruption that spontaneously
heals itself without permanent consequences. The
disease was originally described in 1968 by Dr.
Warren Macaulay.1 Occasionally, the disease will
convert to a cellular malignancy like Hodgkin’s
disease and then disseminate throughout the
body. The basic pathophysiologic disturbance is
the proliferation of monomorphic bizarre histo-
cytic cells in the dermis. This proliferation forms a
clinically detectable nodule, which often ulcer-
ates. These nodules will spontaneously disappear
in six weeks to two months. The patient involved
in this paper is a middle-aged black female who
had a 15-year history of recurring nodules, which
finally converted to a fatal form of mycosis
fungoides.

CASE PRESENTATION

At the age of 38, this black female noted the
occurrences of very innocuous small nodules of
the skin. These were first biopsied in 1974. These
showed an abnormal lymphoreticular infiltrate in
the dermis. For the next nine years, these were
followed by her family physician and der-
matologist, and not considered a major factor in
her health status. In 1977, she was admitted to the
hospital for a hysterectomy for prolonged periods.
She was noted to have mild diabetes and hyper-
tension.

In 1983, she was admitted for MOPP therapy
for the diagnosis of atypical lymphoma, made on
her skin lesions. By this time, the skin lesions were
large, ulcerating, and had abnormal lympho-
reticular cells in the dermis with hyperchromatic
pleomorphic nuclei. (See Figures 1, 2 and 3.) This
was repeated in March, 1984. The patient was
undergoing generalized debilitation during this
interval. This included prolonged fevers to 103°F,
weight loss, intermittent adenopathy, and skin

Department of Pathology, Kershaw County Memorial Hos-
pital, 1315 Roberts Street, Camden, S.C. 29020-3798.

FIGURE 1. Large ulcer of left lateral lower leg, which
spontaneously healed.

FIGURE 2. Margin of ulcer left side showing nodularity of
infiltrate (100X).

nodules as before. All nodules ulcerated and still
healed spontaneously.

In the next three years, she had admissions
primarily for the control of diabetes. In early
1987, she was admitted to Richland Memorial
Hospital for radiation to a large chest ulcer (ap-
proximately 10.0 cm) and a node in the left axilla
that had not healed. She had also been tried on
interferon without success. She was admitted to

March 1989

113

LYMPHOMATOID PAPULOSIS

Kershaw County Memorial Hospital for the final
time on February 25, 1988. A pleural effusion of
the left lung was thought to be secondary to the
radiation. This was removed by thoracentesis. The
patient’s condition worsened and she expired ap-
proximately two days later on March 3, 1988.

FIGURE 3. High power view showing large numbers of
abnormal lymphoreticular cells with hyperchromatic
pleomorphic nuclei (X400).

DISCUSSION

Most original papers conclude that this disease
is a recurrent chronic skin eruption, which re-
mains benign in its course. It is characterized as a
recurrent ulcerating skin condition with an
atypical lymphoreticular infiltrate, which heals
spontaneously. This is summarized in well-
documented review articles by Dr. Macaulay,
Drs. Black and Jones, and Drs. Valentino and
Helwig.2' 3’ 4

In rare instances, it has been noted that the
patient develops reticulum cell lymphoma and
expires.3

This case presents a benign course for approx-
imately ten years and then in the last two years a
persistence of a large ulcer of the sternal skin and
axillary lymphadenopathy. Local radiation was
performed and then death followed much the
same as a case of Doctor Black’s.3

The most intriguing questions raised are at
what point did the patient develop mycosis

114

fungoides? Did the patient’s immune system fi-
nally succumb to persistent stimulus of the his-
tiocytic cells? These questions are yet to be
answered.

From a histological perspective, one observes
the same abnormal lymphoreticular cell in the
dermis in the original biopsy in 1974, in subse-
quent biopsies in 1983, and shortly before her
death in 1987. This raises the additional question
as to whether this disease should have another
name from its inception to include the clinical
course of mostly being benign but with a potential
malignant outcome.

The abnormal cell has the potential to develop
into mycosis fungoides as in our case, large cell
anaplastic lymphoma, or Hodgkin’s disease.5 It is
impossible to tell by looking at the slides which
ulcer is malignant because the atypical cell is
present from the origin, albeit in the malignant
phase it is present in a more anaplastic form and in
larger numbers. It appears to be a disease con-
trolled by host response. Therefore until the ma-
lignant stage develops, the most that can be said
and should be said is “the diagnosis is lympho-
matoid papulosis — mostly benign but potentially
malignant.” □

ACKNOWLEDGMENTS

The author wishes to gratefully acknowledge the review of
the case and comments by Dr. Bernard Ackerman, Dr. Donald
Leonard, Dr. John Maize, Dr. Richard Reed, Dr. h.c.o. Braun-
Falco, Dr. G. Burg, Dr. Martin M. Black, Dr. Loren Golitz, and
Dr. Jim Shaw. Also to be thanked is my personal secretary, Mrs.
Arlene Jones, who typed the manuscript.

REFERENCES

1. Macaulay, W.L. Lvmphomatoid Papulosis: A continuing
self-healing eruption clinically benign — histological malig-
nant. Arch. Dermatology 97: 23-30, 1968.

2. Macaulay, W.L. Lvmphomatoid Papulosis. International
Journal of Dermatology. 17, 204, 1978.

3. Black, M.M. and Jones, E.W. ''Lvmphomatoid Pityriasis
Lichenoides: A variant with histological features simulating
a lymphoma. British Journal Dermatology. 86: 329, 1972.

4. Valentino, A. and Helwig, E.B., Lymphomatoid Papulosis.
Archives of Pathology: 96, 409, 1973.

5. Personal Communications with Dr. Bernard Ackerman.
Dermatopathologist, New York University Medical Center,
New York, New York.

The Journal of the South Carolina Medical Association

NEWSLETTER

MARCH 1989

Register early for the 141st Annual Meeting of the SCMA to be
held April 2 6 through April 3 0 at the Omni Hotel in Charleston.
We have an exciting program scheduled for you including a
workshop on the RBRVS to be conducted by James F. Rodgers, Ph.D.,
Director of The Center of Health Policy Research at the AMA; a
dynamic program on sports medicine with guest speaker John A.
Bergfeld, MD, team physician to the Cleveland Browns Football
Club, Cleveland Cavaliers Basketball Team and orthopaedic
consultant to the Cleveland Indians Baseball Club? and a workshop
on Medical Ethics to be conducted by Nancy Dickey, MD, of the AMA
Council on Ethical and Judicial Affairs. Registration forms and
program schedules have been mailed recently, and we encourage you
to make your reservations promptly. For additional information,
please contact Debbie Shealy of the SCMA staff.

HIGHLIGHTS FROM FEBRUARY SCMA EXECUTIVE COMMITTEE MEETING

At its meeting on February 16, the SCMA's Executive Committee
decided to request that the Medical Ethics Committee prepare an
opinion on the ethical considerations involved in referrals for
second opinions.

Dr. Rowland, President, reported on the Governor's letter of
appreciation for the SCMA's Personal Care program. The SCMA's
involvement in DHEC's Minority Health Care Task Force and DHEC's
Physician Award for volunteer services were noted.

Dr. Hawk, Chairman of the Board, reported that he had received
favorable comments regarding the SCMA's Leadership Conference.
The Executive Committee decided to continue to hold the
Leadership Conference in January.

The Executive Committee was updated on the plans for a mobile
health van by the Governor's Office. This van will provide
health screening and education beginning at worksites in
Beaufort, Jasper, Colleton and Hampton counties. The SCMA has
emphasized the need for physician follow-up of abnormal test
results .

Continued concern with the wording of Medicare Explanation of
Medical Benefit (EOMB) forms was discussed. Since this wording
is a result of national policy, the SCMA will write the AMA's
Council on Medical Service to request further negotiations with
HCFA on revisions of this beneficiary form.

HEALTH EDUCATION VAN UNVEILED

The SCMA/SCMAA/SCIMER and Department of Education's Health
Education Van was unveiled to the general public at a news
conference late last month. The van concept has been well-
received by the media and the general public as well as by the
South Carolina public school system. The van and exhibits will
be on display at the SCMA's Annual Meeting in late April. The
auxiliary expresses their appreciation for your support and
financial contributions in helping to make the project a success.

MEDICARE UPDATE

Effective for services provided on or after April 1, 1989, claims
(from independent labs, radiologists, pathologists, or any other
service rendered as a result of an order or referral from another
physician) must include both the name and provider number of the
ordering or referring physician. Please refer to the March 1,
1989 Blue Cross/Blue Shield information or call your Medicare
provider representative.

MEDICAID UPDATE

Certified Nurse Midwife Coverage

Medicaid will enroll and make payment to certified nurse midwives
(CNM's) for services they are legally authorized to furnish by
state law. A Medicaid bulletin with specific billing
instructions is being sent to all physicians.

Coverage For Breast Reconstructive Surgery

Effective with dates of service on March 1, 1989, the Medicaid
program will consider the expenditure of funds for reconstructive
breast surgery following a mastectomy due to carcinoma of the
breast. All requests for breast reconstruction must be prior
authorized by Medicaid. Approval will be based on specific
criteria for medical necessity. For more detailed information,
please contact HHSFC, Department of Physician Services, at 253-
6134.

Pediatric Coverage

HHSFC has developed an incentive package that includes an
enhanced fee for routine newborn care, a home visit for each
newborn, increased EPSDT rates with increased efforts for
recruitment of more private physicians, and promotion of
additional sick child examinations for children under the age of
21. The increased reimbursement rates, with the additional
service components, will be effective March 1, 1989, as follows:

Fee

Code Description

S9650 Physician's referral to WIC, first $15.00

EPSDT appointment and eligibility
referral to DSS, and referral to
appropriate provider for home visit
within seven days of hospital discharge.

51503 Completion of High Risk Channeling

or Risk Assessment Form 204.

51504

Increased from
$15.00 to
$20.00

90757 Home visits for infant care and $65.00

assessment. Home visit will be
performed by DHEC district office.

Approved physicians and hospitals
may also participate; for information,
contact your program manager.

(Use of Increased rate for all enrolled
1724 EPSDT screeners, (including

Screening physicians, clinics and health
Forms) departments) for five EPSDT

screenings in the first year.

90020 Sick baby follow up visit.

S9660 NICU baby follow up visit for

new patient examination.

Increased from
$35.00 to
$45.00

$50.00

$80.00

Appropriate
level of
office visit
Cpt-4 Code

Unlimited follow up office visit
for treatment of problems found
through EPSDT screening.

Effective April 1, 1989, Medicaid benefits will be available to
women and infants (up to age 1) whose family income level is
below 125 percent of the federal poverty level. Additionally,
children up to age six (born after September 30, 1983) whose

family income level is below 100% poverty will be available for
Medicaid benefits.

The expansion of Medicaid benefits to these groups is intended to
increase their access to health care in the developmental years
and to increase use of prenatal care.

PRO UPDATE

Carolina Medical Review, the name in South Carolina for our new
PRO, Medical Review of North Carolina, has mailed a February 27
memorandum to all practicing S.C. physicians. This
correspondence provides information on Medicare and Medicaid
preadmission review requirements. These requirements were
effective for procedures scheduled March 1 and thereafter. An

important new federal requirement is that preadmission review
must occur for selected procedures if they are performed on an
outpatient basis or in ambulatory surgery center in addition to
inpatient hospital admissions. If you have not received this PRO
memorandum or the related review criteria, contact Carolina
Medical Review.

The phone number in Columbia for Carolina Medical Review is 731-
8225. All preadmission review calls should be made by calling
the Raleigh office 1-800-331-4690.

Blue Cross/Blue Shield has clarified that physician claims are
not required to include the PRO preauthorization number. A
Medicare advisory will be forthcoming.

CHANGES IN WORKMAN'S COMP

As a result of a study the SCMA had Ernst and Whinney conduct,
the Industrial Commission has increased conversion factors for
Workman's Compensation. New conversion factors effective April
1, 1989, are as follows:

Service Type

Medical and Surgical
Radiology - Total
Radiology - Professional
Anesthesiological
Nurse Anesthetist

New Conversion Factor

16.0

15.0
3.5

20.0

16.0

Under the Worker's Compensation medical fee schedule in South
Carolina, relative value units of certain procedures were
outdated and needed to be adjusted to reflect common practice.
The SCMA Occupational Medicine Committee has been instrumental in
assisting the Industrial Commission. Compared to local benefit
plans in particular, as generally supported by the existing
workers' compensation medical fee schedules in nearby states, the
South Carolina schedule needed to be adjusted to a level which
would provide adequate remuneration while maintaining the
availability of quality medical care.

CHANGES IN IRS CODE

It is important that you evaluate your employee benefits in
regards to the recently revised Section 89 of the Internal
Revenue Code. This section deals specifically with non-
discrimination in health and welfare benefits.

Under the revised section, all employers, regardless of business
type or number of employees, must comply with Section 89 to avoid
severe penalties. Complex testing and qualification requirements
must be met. The impact of the requirements of Section 89 can be
SUBSTANTIAL. All employer sponsored health benefits must be
tested, such as medical, HMO, dental, drug, life, AD&D, and

Section 125 flexible benefits plans. Any benefits under Section
132, such as company parking, employee discounts, etc. also fall
under Section 89.

HCFA ADMINISTRATOR PROMOTED

William L. Roper, MD, HCFA Administrator, has been promoted under
the Bush Administration to Deputy Assistant for Economic and
Domestic Policy. In this role he will serve as President Bush's
advisor on health policy matters. Dr. Roper's successor at HCFA
remains to be named at the time "SCMA Newsletter" went to print.

NEW CHAMPUS TELEPHONE NUMBERS

There are two CHAMPUS Provider Reps for South Carolina. Fran
Herlong covers the Charleston, Beaufort and Hilton Head areas
(telephone: 912/263-5145) ; the rest of South Carolina is covered
by Marilyn Mims (telephone: 919/847-5824) .

AIDS UPDATE

The Bureau of Preventive Health Services at DHEC has developed an
HIV/AIDS Laboratory Evaluation Protocol to facilitate HIV/AIDS
staging on the spectrum of progression from infection to disease
as well as management of newly diagnosed HIV-positive DHEC
clients. For a copy of the protocol or additional information,
please call Robert T. Ball, Jr., MD, at 737-4040.

HIV BLOOD TEST COUNSELING GUIDELINES AVAILABLE

AMA physician guidelines on HIV blood test counseling are
available to interested physicians. For a copy, please refer to
the December 9, 1988, issue of American Medical News or contact
Desiree Goodwin at (312) 645-4526.

SC HANDICAPPED SERVICES INFORMATION SYSTEMS

The SC Handicapped Services Information System (SCHSIS) provides
information to persons of all ages with disabilities. Included
in their services is an Elderly Assistance Line, a referral
system for services available to persons age 55 and over. Also
included is a statewide Central Directory for the 0 to 3 -year-old
population with special needs and their families.

Physicians who provide services to both populations who need
information for their patients, and/or physicians who wish to be
listed in the Central Directory for either or both population
groups, should call 1-800-922-1107 (in Columbia 777-5732) .

CHOLESTEROL CME VIDEO TAPE AVAILABLE

The National Cholesterol Education Program (NCEP) of the National
Heart, Lung, and Blood Institute is pleased to announce the
immediate availability of a continuing medical education,

independent study, monograph on cholesterol. It is titled
Cholesterol: Current Concepts for Clinicians. Copies are
available free of charge, on request, to individual physicians
and to CME directors who are conducting CME courses for local
physician groups. For more information, please contact National
Cholesterol Education Program, Box CME, 4733 Bethesda Ave, Suite
530, Bethesda, MD, 20814. Telephone number is (301)951-3260.

RESEARCH GRANTS AND FELLOWSHIPS AVAILABLE

The American Heart Association is accepting applications for
research grants and fellowships in the following areas:

MEDICAL STUDENT RESEARCH FELLOWSHIP

Institutional award to encourage full-time research training
for one or more years prior to graduation.

CLINICIAN SCIENTIST AWARD

To encourage promising clinically trained physicians to
undertake careers in investigative science.

ESTABLISHED INVESTIGATOR

To assist promising physicians and scientists to develop
independent research careers in academic medicine and
biology.

GRANT-IN-AID

Research project broadly related to cardiovascular function
and diseases, including stroke, or related fundamental
problems. Support available for all basic disciplines and
for cardiovascular epidemiological and clinical
investigations .

For additional information, please contact Jan Samuel at 738-9540
in Columbia.

TELECONFERENCE TO BE HELD

The AMA will host a teleconference on March 23 on RVS : What It
Means for the Practice of Medicine. The program will be aired by
the Hospital Satellite Network from 2:30-4:00 p.m. Call 1-800-
537-5393 for additional information. Cassettes of the program
may be ordered from the AMA by calling 1-312-645-5102.

CONFERENCES TO BE HELD

The AMA will sponsor an International HIV Conference on
Counseling, Testing and Early Care on June 3 & 4 at the
Bonaventure Hilton International in Montreal, Quebec, Canada.
For additional information, please contact John H. Henning,
Ph . D . , Director of AMA's HIV/AIDS Office, at (312) 645-4566.

PROJECT READINESS II: SOME RESULTS
FROM A PHYSICAL FITNESS AND HEALTH
ENHANCEMENT PROGRAM FOR LAW
ENFORCEMENT PERSONNEL*

STANLEY J. LePROTTI, M.ED.
WARREN K. GIESE, PH.D.

JOHN H. SPURGEON, PH.D.

JAMES A. KEITH, PH.D.**

STANLEY S. JUK, JR., M.D.
CLARENCE G. ROBINSON, M.D.
SANDOR MOLNAR, PH.D.***

J. DAVID BRANCH, M.S.

Since the early 1970s, crime, citizen safety,
recruitment, funding, retention of personnel, and
other police related matters have been closely
scrutinized by law enforcement agencies, the me-
dia, and government committees. Somewhat
belatedly, it was recognized that among the nu-
merous facets of law enforcement none was more
important than the health of the law enforcement
officer. Besides the primary value of officer
health, it was recognized that the dollar costs of
disability, early retirement and medical care
placed acute financial strains on local taxing
districts.

THE PROBLEM IDENTIFIED

Police work involves occupational extremes: (1)
sedentary activities much of the time; and (2)
unpredictable violent encounters on occasion.
Coupled with this vacillating quiet-violent stress
pattern are frequent “rotating shifts,” requiring
irregular eating and sleeping patterns, often inad-
equate physical exercise, sometimes domestic up-
heaval, and other job-related conditions that

From the Department of Physical Education (Mr. Le-
Protti, Dr. Spurgeon and Dr. Giese) and the School of
Public Health (Dr. Keith), University of South Carolina,
Columbia; Columbia Cardiology Associates, P. A., Colum-
bia, S. C. (Dr. Juk); the New York City Police Department,
New York, N. Y. (Dr. Robinson); and the Department of
Physical Education, Furman University, Greenville, S. C.
(Dr. Molnar and Mr. Branch).

Address correspondence to Dr. Keith at the School of
Public Health, University of South Carolina, Columbia,
S. C. 29208.

Deceased

contribute to medical and social problems.
Among law enforcement personnel, heart disease,
high blood pressure, gastro-intestinal disorder,
kidney disease, low back pain, and a variety of
nervous disorders are seen more often than in the
general population.

A NIOSH1 study found that at any given time,
from 10 percent to 37 percent of the officers
surveyed had serious marital, family, alcohol and
drug problems. Compared with the population at
large, alcoholism, suicide and divorce are each
higher among law enforcement personnel. Effec-
tive law enforcement requires more than minimal
levels of physical fitness and dynamic health; too
often these requirements have not been recog-
nized. Exemplary of positive actions are studies in
Los Angeles, New York City, Salina, Kansas, and
Columbia, South Carolina.2- 3

PROJECT READINESS II

The needs described above were recognized by
law enforcement leaders in South Carolina. Dur-
ing the fall, 1979, in cooperation with the Univer-
sity of South Carolina, a pilot program was
designed to improve the health status and physical
fitness of law enforcement personnel. The pro-
gram was designated Project Readiness. Compo-
nents of the program were physical training,
nutrition education, weight reduction, and stress
management. This program was the most com-
prehensive attempt to date focused on improving
the physical and health fitness of law enforcement
personnel and was sufficiently successful that

March 1989

119

PROJECT READINESS II

Project Readiness was organized and initiated
during the fall of 1980.

SUBJECT AND DATA COLLECTION

The subjects were 178 law enforcement officers
at city, county, state and federal levels (Federal
Bureau of Investigation, United States Secret Ser-
vice, United States Marshals, Bureau of Alcohol,
Tobacco, and Firearms, South Carolina Law En-
forcement Division, South Carolina Highway Pa-
trol, South Carolina Wildlife and Marine Re-
sources Department, Richland and Lexington
County Sheriff ’s Departments, and the Columbia,
Cayce and West Columbia, South Carolina city
police departments) ranging in age from 21 years
to 66 years, with the average near 35 years. On
each subject, demographic, nutritional, person-
ality, motivational, somatic and physiological
data were collected. Specifically, each participant
completed demographic and diet recall question-
naires, responded to a psychological profile, and
was tested for resting blood pressure, resting pulse
rate, pulmonary function, intraocular eye pres-
sure, 12-lead electrocardiogram, blood chemistry,
26-item panel, ergometer stress test and measures
of body size, form and composition.

After completing the above, subjects began at-
tending physical workouts held at the Blatt Phys-
ical Education Center, University of South Caro-
lina. These workouts were under the direction of
Stan LeProtti and his staff (a complete description
of the workout regimen is available upon request).

SHORTCOMINGS OF PHYSICAL
ACTIVITY DATA

Attendance at the workout sessions on a volun-
tary basis resulted in 10 percent of the men report-
ing for 30 to 60 percent of the sessions; 33 percent
reported between 20 percent and 29 percent of
the time and 57 percent were present for less than
20 percent of the sessions. This level of response
underscores the ineffectiveness of a voluntary
program and supports the notion that maximal
results can be obtained only when a program is
mandatory. Reasons for poor attendance were
cited as rotating duty shifts, unforeseen emergen-
cies and changes in duty assignment. Despite re-
duced attendance, some beneficial results of the
physical activity were found. Physical activity
was complemented with lectures on nutrition and
when necessary, counseling on weight reduction.

120

Sixty-two of the participants were available for
post-testing.

DEMOGRAPHIC FINDINGS

Response to demographic questions was in-
complete; but for those responding about half
were native South Carolinians, and the remaining
officers were native to 15 other states. Nearly 90
percent of the officers were white, slightly more
than half were married, about one-third were
single and the others were divorced.

About half the respondents graduated from
high schools having small (less than 100) graduat-
ing classes and half from larger schools.

More than half of the respondents were first or
only children; of those reporting children, female
children were more prevalent than male children.

Nearly two-thirds of respondents either had
never smoked or had quit smoking.

NUTRITIONAL FINDINGS

A 24-hour dietary recall inventory was admin-
istered to a subsample (N = 42) of the law enforce-
ment group.

In general, dietary habits were not good. Missed
meals was the rule rather than the exception.
Fewer than one-third of the respondents had
breakfast each morning, nearly two-thirds had a
daily noon meal; about 90 percent had an evening
meal which included more than half their daily
caloric intake. No real patterns exist for the con-
sumption of meat products (red meats and
chicken were preferred) breads, milk or milk
products, fruits or vegetables, except that large
quantities of “fast foods” or “snacks,” i.e. ham-
burgers, french fries, cookies, milkshakes, milk,
coffee, tea, and soft drinks are listed as being
consumed “between meals.” Average caloric in-
take was near 2,800 Kcal which is reasonably close
to the recommendations made by the National
Academy of Sciences.4

PHYSIOLOGICAL FINDINGS

All clinical testing was conducted in the labora-
tories of the Department of Physical Education
between the hours of 8:00 and 5:00 p.m.

The following tests were taken with the subjects
in a sitting position: resting heart rate (RHR),
resting blood pressure (RSP/RDP), forced vital
capacity (FVC), and forced expiratory volume
(FEV 1.0). Following eight hours of fasting, a 12

The journal of the South Carolina Medical Association

PROJECT READINESS II

lead resting electrocardiogram (ECG) was
obtained with the subjects in a supine position.
Medical interpretation of the ECG test was fol-
lowed by a bicycle ergometer graded exercise test
(BEGXT), during which the heart rate was moni-
tored every few seconds. Methodology and mea-
surement reliability are discussed elsewhere.5’ 6- ~ 8

Pre-test RHR values ranged from 37-100 beats/
min. (X + 66. 5 + / — 10.7). Pre-test resting blood
pressure values ranged from 94-170 mm Hg
(X = 124. 2 + / — 13.1) and 10-110 mm Hg
(X = 79.5 + / — 11.0) for RSP and RDP respec-
tively. As these data indicate, several subjects pre-
sented values above the generally accepted
hypertension criteria of 150 mm Hg and/or 90
mm Hg. Pre-test FVC (X = 4.8 liters H- / — 0.8)
and FEV 1.0 (X= 3.7 liters H- / — 0.7) were nor-
mally distributed, with ranges of 2. 8-6. 8 liters and
1.7-5. 9 liters respectively.

The mean post-test RHR was 63.5 beats/min
( H- / — 11.9), with a range of 35-106 beats/min
(N = 60). Post-test RSP and RDP means were
123.8 mm Hg ( H- / — 13.4) and 79.5 mm Hg
( + / — 8.2). Post-test RSP ranged from 106-180
mm Hg, with an RDP range of 68-110 mm Hg.
Post-test FVC and FEV 1.0 means were 4.8 liters
( + / — 0.9, range 2.5-7. 0) and 3.7 liters ( + / — 0.8,
range 1.6-5. 7) The pre-test and post-test mean
differences in RHR, RSP and FVC possibly reflect
a modest training effect. No change was observed
in pre-test and post-test RDP and FEV 1.0 means.

The heart rate response of this population to
incremental cardiovascular exercise compares fa-
vorably with previously published reports.9 Heart
rate will increase linearly in response to incremen-
tal work; however, the slope of the line represent-
ing the heart rate response will vary as a function
of cardiovascular fitness. Comparison of pre-test
and post-test heart rate response in the BEGXT
(25 Watt initial workload, increasing 25 Watts/
minute) reflects a lower slope of post-test heart
rate progression; a generally accepted indication
of increased cardiovascular fitness.

Means and variability statistics for 28 blood
chemistry variables are presented in Table 1. All
means were within the normal range of limits as
defined by Biomedical Reference Laboratories,
Inc., Burlington, North Carolina. Large devia-
tions from the mean were observed for triglycer-
ides, VLDL-cholesterol, SGOT, CPK and LDH.
These findings are similar to Project Readiness I

data. Empirical comparison of data of Project
Readiness I and II show a modest increase in mean
HDL-cholesterol, a possible reflection of in-
creased exercise and nutritional awareness.

SOMATIC FINDINGS

Data were obtained for two measures of body
size (height and weight) and a measure of body
composition (percent body weight fat). The direct
measures were taken with subjects wearing shorts
only. Methodology and measurement reliability
are discussed elsewhere.11- 12

Means for standing height, body weight and
body weight/fat were 176.5 cm, 80.1 Kg and 19.8
percent respectively. The means for standing
height and body weight were higher by .7 cm and
.2 Kg than for similar means obtained from an
American survey made during 1971-74 on 2,234
United States men between ages 25 and 54 years.
For each comparison, it is not tenable at P>. 05 to
infer population differences.

In spite of irregular workout sessions, post-test
body fat [fat (% body weight) ] decreased by 3.2
percent (P<.05).

About half the group appears to be overweight.
deVries has suggested that when 15 percent body
weight/fat has been reached, weight reduction is
in order.14

PERSONALITY TEST PROFILES

A 10 bi-polar personality factor profile resulted
from the administration of the Motivational
Analysis Test.15 This test gives an individual’s
interests, drives, and the strength of his sentiment
and value systems. Five of the measures are basic
drives-ergs and five are sentiment structures. The
five ergs are mating, assertiveness, fear, nar-
cissim-comfort, and pugnacity-sadism. The five
sentiment measures are self-concept, superego,
career, sweetheart-spouse, and home-parental.
Reliability measures for the ten dynamic factors
range from .33 to .71 while validity ranges from
.53 to .76 respectively.

The profile of ergs and sentiments is reported in
total motivation scores, converted to stens, and
averaged for the group. Averaged scores falling
between sten 4V2 and 6Vz are considered to be
within the “normal’’ range and unremarkable
from the normative group. Those falling outside
of this range are considered to be descriptive of

March 1989

121

PROJECT READINESS II

TABLE 1

Means and Standard Deviations for Blood Composition
Measurements (N = 74)

Variable Name

Mean

Standard

Deviation

Minimum

Maximum

LDL Cholesterol

129. 361

29.57

56.0

234.0

VLDL Cholesterol

28. 541

15.10

2.0

75.0

HLD Cholesterol

47. 551

14.22

24.0

92.0

Total Cholesterol

205. 911

32.48

116.0

302.0

LDL/HDL Ratio

2.93

1.19

0.9

6.8

Triglycerides

144. 731

73.32

12.0

376.0

CHD Risk

1.13

0.81

0.3

5.25

BUN

14. 651

3.84

8.0

27.0

Creatinine

1.191

0.21

0.8

1.8

BUN/Creatinine Ratio

12.46

3.14

6.9

23.3

Uric Acid

6.531

1.22

4.2

9.1

Calcium

9.74

0.39

8.9

10.6

Phosphrous

3.461

0.49

1.9

4.5

Glucose

99. 311

17.62

65.0

162.0

Sodium

140. 203

1.74

136.0

145.0

Potassium

4.433

0.45

3.3

5.4

Chloride

99. 643

3.09

88.0

106.0

C02

29. 613

3.35

15.0

35.0

Albumin

4.794

0.32

3.9

5.6

Globulin

2.634

0.31

2.1

3.4

Total Protein

7.434

0.41

6.6

8.5

Albumin/ Globulin Ratio

1.84

0.26

1.1

2.5

Total Bilirubin

.761

0.31

0.3

2.2

SGOT

32. 652

36.65

14.0

244.0

Alkaline Phosphatase

76. 432

22.69

39.0

149.0

Lactic Dehydrogenase

182. 732

32.05

125.0

362.0

Osmolality

290. 285

3.64

281.0

299.0

CPK*

165. 582

83.51

71.0

432.0

*N=73

Units of Measurements
1= mg.dl”! 2=mIU.ml“l

3=mEq.L“l

4=g.dl“l

5=mosm.“l

122

The Journal of the South Carolina Medical Association

PROJECT READINESS II

Figure 1

Motivational Analysis Test Profile

Standard Ten Score (STEN)

1 2 3 4 5 6 7 8 9 10

Career

Sentiment

Low

Home-Parental

Sentiment

Low

Fear

ERG

Low

Narclsm-Comfort

ERG

Low

Superego

Sentiment

Low

Self-

Sentiment

Low

Mating

ERG

Low

Pugnacity-Sadism

ERG

Low

Assertiveness

ERG

Low

Sweetheart-Spouse

Sentiment

Low

Career

Sentiment

High

Home-Parental

Sentiment

High

Fear

ERG

High

Narcism-Comf ort
ERG
High

Superego

Sentiment

High

Self-

Sentiment

High

Mating

ERG

High

Pugnacity-Sadism

ERG

High

Assertiveness

ERG

High

Sweetheart-Spouse

Sentiment

High

March 1989

123

PROJECT READINESS II

how the profile group varies from the nor-
mative— hence, the characteristics which are
unique to this homogenous group.

The profile for this group of subjects (Figure I)
shows variation on six of the 10 ergs and senti-
ments. In the profiled group of subjects, the nar-
cissim-comfort erg is substantially higher than
normal and indicates that this group is directed to
sensual indulgence (food, smoking), to ease, self-
love, and avoidance of onerous duties. A second
characteristic which varies from the norm is low
superego sentiment which is the strength of devel-
opment of conscience. Self-sentiment was higher
than normal for this group and indicates a
stronger level of concern about the self-concept,
social repute, and more remote rewards. The pug-
nacity-sadism erg was higher than normal and
measures the strength of destructive-hostile im-
pulses. The assertiveness erg of the strength of the
drive to self-assertion, mastery and achievement
for the group was lower than for the normative
group and the sweetheart-spouse or strength of
attachment to spouse or sweetheart was higher
than normal.

These results clearly indicate that differences
exist between this group and the normative popu-
lation. Such differences often serve to describe
groups of people who are homogenous in certain
aspects, i.e., occupation, sex, age or physical
condition.

PROJECT ASSESSMENT

By far the most valuable aspect of Project Read-
iness II was the medically supervised clinical
screening. A number of health problems were
discovered and appropriate follow-up taken. So
successful was the clinical screening program that

124

state funding was established to implement Proj-
ect Readiness III which will serve five state agen-
cies involving approximately 1,200 State Police. □

REFERENCES

1. Blackmore, J: Are police allowed to have problems of their
own? Police Mag, 45-47 (July) 1978.

2. Mealey, M: New fitness for police and firefighters. Phys.
Sports Med 7:96-100, 1979.

3. LeProtti, S.J.; Giese, W.K.; et al: Project readiness: Results
from a physical fitness and health enhancement program
for law enforcement personnel. Spectrao Authro Prog 7,
43-53, 1985.

4. Nutrition National Academy of Sciences: Recommended
Dietary Allowances, Ninth Revised Edition (Washington.
D.C.) 1980.

5. Multiple Risk Factor Intervention Trial Group: The multi-
ple risk factor intervention trial — a national study of pri-
mary prevention of coronary heart disease. JAMA
235:825-827, 1987.

6. Warren E. Collins, Inc.: 200 Wood Road, Braintree. Mass.
02184.

7. Wilson, P.K.; Faudy, P.S.; Froclicher. V.F.: Cardiac re-
habilitation, adult fitness and exercise testing, Phila-
delphia, 1981: Lea and Febriger.

8. Biomedical Reference Laboratories, Inc.: Burlington. NC
27215, under Panel 22616.

9. Vauder, A.J.; et al: Human physiology — the mechanism of
body function, McGraw-Hill Co., New York, 1982.

10. Powell. F.M.; Molnar, S: Concepts in physical fitness — a
laboratory manual, Burgess Publishing Co., Minneapolis.
1978.

11. Brozek, J.: Keys, A.: The evaluation of leanness-fatness in
man: norms and interrelations, Brit J Nutu, 5:194-206,
1951.

12. Spurgeon, J.H.; Sargent, R.G.: Measures of physique and
nutrition on outstanding male swimmers. Swimming
Technique, 15:26-32, 1978.

13. National Center for Health Statistic: Height and weight of
adults 18-74 years of age in the United States, U.S. Depart-
ment of Health, Education and Welfare, No. 3, 1976.

14. deVries, H.A.: Laboratory experiments in physiology of
exercise, William C. Brown Co., Dubuque, Iowa, 1971.

15. Cattel, R.B.; et al: Handbook for the motivational analysis
test “MAT,'' Institute for Personality and Ability Testing,
Champaign, IL 1984.

The Journal of the South Carolina Medical Association

CIPROFLOXACIN: PANACEA OR BLUNDER DRUG?

While attending a meeting in Europe some
years ago, I kept encountering names of anti-
microbial compounds of which I had never heard.
Finally, I summoned the courage to ask an Italian,
“What’s that?” “It’s one of the DNA gyrase inhib-
itors,” he replied. I hid my ignorance: “Why, of
course.” Actually, I had never heard of DNA
gyrase — let alone its inhibitors! After extensive
use in other parts of the world, the fluoro-
quinolones have now fully arrived in the United
States as norfloxacin (Noroxin) and ciprofloxacin
(Cipro). More will follow. The timely paper by
Dunbar and colleagues in this issue of The Journal
attests to the current wide interest in the role of
ciprofloxacin in medical practice.

To the best of my knowledge, the study by
Dunbar and colleagues represents the first state-
wide multi-practice collaborative drug trial ever
reported in The Journal. It illustrates the poten-
tial for office practitioners to generate data rele-
vant to day-to-day medical practice. However,
the study should be interpreted cautiously. Micro-
biologic documentation of infection was obtained
in only 14 of the 113 patients treated. More impor-
tantly, there was no comparison group. A com-
parison of ciprofloxacin with the drugs the
physicians would otherwise have chosen had they
not been participating in this industry-sponsored
study would have been of interest. More than one-
third of the infections treated were community-
acquired lower respiratory tract infections, for
which ciprofloxacin is not considered to be a drug
of choice. Despite these caveats, the study con-
firms the remarkable efficacy and safety of this
new class of antimicrobials. What, then, is the
proper place of ciprofloxacin in our armamen-
tarium?

A current advertisement for ciprofloxacin touts
its ability to “bring the power of parenterals to
office practice.” This power applies mainly to
aerobic gram-negative rods, including Pseudo-
monas aeruginosa. With the addition of cipro-
floxacin— and also of third-generation cephalo-
sporins that can be administered orally — we can

anticipate a definite trend toward oral antibiotic
therapy for infections that previously would have
required parenteral agents. For most of the other
pathogens encountered in office practice, we have
equally- or more-effective older drugs suitable for
oral administration. It is not at all clear that
ciprofloxacin should replace such old stand-bys
for oral therapy as erythromycin, doxycvcline,
ampicillin, trimethoprim/sulfamethoxazole (Bac-
trim; Septra), metronidazole (Flagyl), and amoxi-
cillin/clavulanate (Augmentin). Hence, a brief
review of the pharmacology and spectrum of
activity of this new agent seems appropriate.

Fike the third-generation cephalosporins, the
synthetic fluroquinolones are in essence “designer
drugs” — in this case, patterned after nalidixic
acid (NegGram). Inhibition of bacterial DNA gy-
rase makes these agents bactericidal not only
against dividing cells but also against resting
cells — a remarkable feat. At concentrations of less
than one mcg/ml, ciprofloxacin is active against
most of the Enterobacteriaceae (the common
aerobic gram-negative rods), Haemophilus,
Neisseria, Pseudomonas, and Acinetobacter spe-
cies, and most staphylococci. Streptococci — in-
cluding the pneumococcus — are, in general, not
highly susceptible.1 That obligate anaerobes are
usually resistant to the fluoroquinolones is not
altogether undesirable, since there is much to be
said for leaving the anaerobic intestinal flora in-
tact in the course of non-intraperitoneal infec-
tions. Ciprofloxacin is also active against most
mycobacteria, including M. tuberculosis,2 and
against Legionella species and various rickettsia.
There is even more good news. Emergence of
resistance to the fluoroquinolones, which occurs
by single-step gene mutation, has been uncom-
mon. Resistance has occurred mainly after treat-
ment of Pseudomonas aeruginosa infections in
patients with cystic fibrosis3 or treatment of meth-
icillin-resistant S. aureus infections.4 In short,
ciprofloxacin seems almost too good to be true.
What is the downside?

First and perhaps foremost are its contraindica-

March 1989

131

tions. An effect on the growing cartilage of
weight-bearing joints makes it contraindicated in
children and in pregnant women. Second, one
must keep in mind certain clinically-important
drug interactions. Inhibition of the metabolism of
theophylline leading to increased theophylline
blood levels has received the most publicity, but
ciprofloxacin also impairs the metabolism of caf-
feine and antipyrine. Antipyrine is considered to
be a marker of broad substrate specificity, and
hence it would seem best to avoid when possible
the combined use of ciprofloxacin with drugs that
are metabolized by the liver and have low
therapeutic indices — such as cyclosporin, pheny-
toin (Dilantin), and warfarin (Coumadin). El-
derly patients and patients with liver disease are
especially vulnerable to such drug interactions.5
Finally, achievable serum concentrations are rela-
tively low, usually ranging between 1.5 and 2.9
meg/ ml after a single 500 mg orally-administered
dose.6 Hence, ciprofloxacin — at least when given
orally — does not afford the extremely high kill
ratios generally considered to be necessary for
therapy of such infections as endocarditis, men-
ingitis, or sepsis in neutropenic cancer patients.
Still, it is apparent that ciprofloxacin should be
both effective and safe for the majority of infec-
tions in adult patients encountered in office prac-
tice. When, then, should it be used?

Let us consider the alternatives. For respiratory
tract infections, one should remember that the
activity of fluoroquinolones against S. pneu-
moniae (the pneumococcus) is far less than that of
other agents. Hence, ciprofloxacin should not be a
first choice for therapy of community-acquired
pneumonia." For non-allergic patients, the pen-
icillin derivatives remain the preferred agents.
For urinary tract infections, we already possess a
plethora of effective agents including the sul-
fonamides and trimethoprim/sulfamethoxazole
(Bactrim/Septra). For soft tissue infections likely
to involve staphylococci, including bite wounds,
amoxicillin/clavulanic acid (Augmentin) would
seem preferable. For heavily-infected ulcerations
(such as the diabetic foot or decubiti), the com-
bination of either of the aforementioned agents
with metronidazole (Flagyl) would seem a better
choice. For these and indeed for most commu-
nity-acquired infections, ciprofloxacin has not

132

been shown to be superior to older agents.

Still, ciprofloxacin seems to have certain unique
niches. These include the following:

(1) Pseudomonas aeruginosa infections out-
side the urinary tract, for which ciprofloxacin is
the first effective orally-administered agent.
Considerable experience documents the effica-
cy of ciprofloxacin for Pseudomonas bone and
joint infections. Its contraindications in child-
hood is unfortunate especially because of its
efficacy in nail puncture wound-associated
Pseudomonas osteomyelitis.

(2) Infectious diarrheas. Ciprofloxacin has re-
markable activity against nearly all of the clas-
sic enteric pathogens, including Salmonella
typhi.

(3) Post-hospitalization therapy of infections
acquired in the hospital and due to the more
difficult-to-treat gram-negative rods, such as
Klebsiella, Enterobacter, and Serratia species.

(4) Infections due to unusual pathogens, such
as the non-tuberculous mycobacteria. Here,
however, therapy must be individualized.

(5) Antibiotic-resistant strains of Neisseria
gonorrhoeae, for which ciprofloxacin is one of
the few promising drugs.8

So great is the activity of ciprofloxacin, however,
that it seems inevitable that this list of specific
indications will grow.

Ciprofloxacin, in summary, is a welcome addi-
tion to our armamentarium which can spare
many patients the need for parenteral antibiotic
therapy. Enthusiasm seems warranted. Still, it
seems prudent in most situations to ask what alter-
native agents might be equally effective and less
costly. And, of course, it need hardly be empha-
sized that the broad-spectrum of activity of
ciprofloxacin does not replace the need for accu-
rate diagnosis whenever possible. The paper by
Dunbar and colleagues reminds us that there is a
definite place for clinical trials of drugs after FDA
approval and marketing.9 Perhaps this paper will
stimulate further multi-practice trials in South
Carolina. This is the kind of activity that both our
association and also the specialty and subspecialty
organizations should encourage.

— CSB

The Journal of the South Carolina Medical Association

REFERENCES

1. Sanders CC: Ciprofloxacin: in vitro activity, mechanism of
action, and resistance. Rev Infect Dis 10: 516-527, 1988.

2. Levsen DC, Haemers A, Pattyn SR: Mycobacteria and the
new quinolones. Antimicrob Agents Chemother 33: 1-5,
1989.

3. Neu HC: Bacterial resistance to fluoroquinolones. Rev In-
fect Dis 10: S57-S63, 1988.

4. Piercy E, Barbaro D, Luby JP, et ah Ciprofloxacin for
methieillin-resistant Staphylococcus aureus infections.
Antimicrob Agents Chemother 33: 128-130, 1989.

5. Davey PG: Overview of drug interactions with the
quinolones. J Antimicrob Chemother 22: Suppl C, 97-107,

ON THE COVER: DOCTORS’ DAY

March 30 is Doctors’ Day. This day which is set
aside to honor our medical doctors was first cele-
brated by the Auxiliary to the Barrow County
(Georgia) Medical Society in 1933. Mrs. Eudora
Brown Almond originated the idea, inspired in
part by her fond memories of the family doctor of
her childhood and in part by her husband, Dr.
Charles B. Almond, and his “dedication, charity,
courage, love and sacrifices in his daily ministry of
healing humanity’s ills. ” March 30, the day that in
1842, Dr. Crawford Long, another Georgia physi-
cian, first used ether as an anesthetic, was selected
as the appropriate day. The Women’s Auxiliary to
the Southern Medical Association adopted the
celebration in 1935.

The lovely illuminated poem on this month’s
cover was not composed for Doctors’ Day but
somehow seems appropriate. It was written and
illuminated by Sister Carmel of Saint Francis
Xavier Infirmary some years ago to honor Dr.
Daniel Lawrence Maguire, long time beloved
Chief of Staff of that institution.

1988.

6. LeBel M: Ciprofloxacin: chemistry, mechanism of action,
resistance, antimicrobial spectrum, pharmacokinetics,
clinical trials, and adverse reactions. Pharmacotherapy 8:
3-33, 1988.

7. Thys JP: Quinolones in the treatment of bronchopulmonary
infections. Rev Infect Dis 10: S212-S217, 1988.

8. Judson FN: Management of antibiotic-resistant Neisseria
gonorrhoeae (editorial). Ann Intern Med 110: 5-7, 1989.

9. Ronald AR: Clinical trials of antimicrobial agents following
licensure. J Infect Dis 159: 3-6, 1989.

Dr. Maguire was born in Charleston in 1882. He
graduated from Bennett School, Charleston High,
and the College of Charleston, each time with
honors. In 1907 he received his M.D. from the
Medical College of the State of South Carolina
where he later served as Clinical Professor of
Surgery. Dr. Maguire was prominent in civic and
church activities as well as in medical concerns.
He married Ella Frances Carter in 1914. Their
union produced three sons and one daughter, all
of whom entered the medical profession. Dr.
Maguire, “a true gentleman, an eminent doctor,
and a dear friend,” died on October 6, 1951.

This cover is dedicated to Dr. Maguire and to all
the dedicated physicians in the state who serve
selflessly in their chosen profession.

— Betty Newsom

The Waring Historical Library

Cover picture courtesy of Carter P. Maguire,
M.D.

March 1989

133

VERA CENTURY AGO,

a thousand visionary physicians across the
nation bestowed a commemorative stone
carving to the Washington Monument. This patriotic
display symbolized their unrelenting devotion to a

new republic founded on
freedoms — including the
freedom to practice medicine
for the best possible health of
all its people. Today your help
is needed to restore this symbol
of our profession.

Because the commemo-
rative stone has suffered from
severe erosion and deface-
ment, the American Medical Association is launching a campaign to raise money from
physicians to restore this symbol of medicine for the National Park Service. Even
contribution made to this effort will serve as a statement of each physician's personal
affirmation and commitment to health and medicine in America.

Please take part in rededicating the commemorative stone as a shining example ot
the strength of medicine in a free and strong society.

Contributors who donate $100 or more will receive a
memorial replica of the carving as a token of appreciation.

Send your tax deductible contribution for this time-
less symbol today. Thank you.

Yes, I want to affirm my commitment
to health and medicine in America.
Please accept my contribution for:

Other

$100

$50

$25

Please make checks payable to:

AMA Stone/National Park Service.
Mail your payment with this form to:
AMA Stone/National Park Service
PO. Box 109016
Chicago, Illinois 60610-9016

Name

Address

City/State/Zip

All donations are tax deductible. All contributions will be publicly recognited in an
unveiling ceremony for the new stone when it is fully restored.

Thank you for your contribution.

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

VOLUME 85 APRIL 1989 NUMBER 4

ONE HUNDRED FORTY-FIRST
ANNUAL MEETING

THE OMNI HOTEL AT CHARLESTON PLACE
CHARLESTON, SOUTH CAROLINA
APRIL 26-APRIL 30, 1989

The 141st Annual Meeting of the South Carolina Medical Association celebrates nine consecutive years
in Charleston and the third year at the Omni Hotel at Charleston Place.

Details of the meeting have been mailed to all physicians in the state, but if you have not received this
information, including pre-registration forms and hotel reservation cards, call SCMA Headquarters in
Columbia (798-6207 or 1-800-327-1021). There is no registration fee for SCMA members. On-site
registration again will utilize computers and word processors, but pre-registration is encouraged to avoid
delays at the registration desk.

The house of Delegates meets in full sessions on Thursday morning, April 27, and Sunday morning,
April 30. Speaker of the House, O. Marion Burton, M.D., will preside with the assistance of Vice Speaker,
Benjamin E. Nicholson, M.D. Reference Committee meetings are scheduled for Thursday afternoon.

A full schedule of scientific sessions on many topics of interest has been planned. Workshops begin on
Wednesday afternoon and continue each afternoon thereafter through Saturday. General sessions are
scheduled for Thursday afternoon on the topic of “Current Concepts in the Management of Sports Related
Injuries” and on Friday and Saturday mornings on the subjects of “Psychiatric Topics for Primary Care
Physicians” and “Occupational and Environmental Health.” Consult the Schedule of Events which
follows for details on all programs. Scientific sessions are jointly sponsored by both South Carolina Schools
of Medicine and AMA Category I credits will be awarded attendees on an hour-for-hour basis. AAFP
Prescribed Credits have been approved by the S. C. Academy of Family Physicians.

Special guests for this annual meeting include John Lee Clowe, M.D., Speaker of the House of Delegates
of the American Medical Association, and the SOCPAC luncheon speaker, John S. Zapp, D.D.S., Director
of Government Affairs for the AMA.

The third Leonard W. Douglas, M.D., Memorial Lecture, established by the S. C. Institute of Medical
Education and Research, will feature as guest speaker, Nancy W. Dickey, M.D., member and former
chairman of the AMA Council on Ethical and Judicial Affairs. Dr. Dickey will speak during the General
Membership meeting on Thursday morning on “Medical Ethics: Where Do They Come From?”

The SCMA Auxiliary will hold its Annual Meeting concurrently with the SCMA, and in addition to the
meeting of the Auxiliary House of Delegates, many special activities have been planned. More specialty
societies will be holding sessions during the /Annual Meeting than ever before. Again, this year, Mead
Johnson Nutritional Division has organized and will provide the prizes for a golf tournament on Friday
afternoon.

The SCMA Board of Trustees will meet on Wednesday, April 26, and at breakfast each day to consider
business which arises during the House of Delegates meeting.

This issue of The Journal contains those reports, Resolutions, and other information available at
publication deadline. Additional reports received after this issue has gone to press will be included in the
Delegates Handbooks which will be mailed prior to the meeting. Delegates are asked to bring their
handbooks to the meeting or to pass them along to Alternate Delegates if they are unable to attend.

-JD

April 1989

145

ONE HUNDRED FORTY-FIRST ANNUAL MEETING

SCHEDULE OF EVENTS

Wednesday, April 26, 1989

TIME/LOCATION

EVENT

7:30 a. m. -8:30 a.m.
Shaftesbury Room

SCMA Board of Trustees Breakfast

8:30 a.m. -12:15 p.m.
Willow I Room

SCMA Board of Trustees Meeting

11:30 a.m. -7:00 p.m.
2nd Floor Grand Hall

SCMA Registration — Open

12:15 p.m. -1:30 p.m.
Jenkins/King Room

SCMA Board of Trustees Luncheon

1:00 p.m.-4:00 p.m.
Suite 2H

SCMAA/SCIMER Scholarship Interviews

1:00 p.m. -5:00 p.m.
Dogwood/Cypress/Live Oak
Ballroom and Grand Hall

Exhibitors Setup

1:00 p.m. -5:00 p.m.
2nd Floor Lobby

Auxiliary Registration — Open

1:30 p.m. -3:00 p.m.
Ashley Cooper Room

SCMA Hospital Medical Staff Section Meeting

1:30 p.m. -5:00 p.m.
Willow I Room

SCMA Board of Trustees Meeting

3:00 p.m. -5:00 p.m.
Drayton Room

SCMA Workshop: “Sexual Dysfunctions”

“Organic Causes”

Barry Bodie, M.D., Columbia
“Psychological Aspects”

Peter Kilmann, Ph.D., University of South Carolina

3:00 p.m.-5:00 p.m.
Colleton Room

SCMA Workshop: “Medical/Legal Aspects of Drug Therapy”
Carl Gainor, Ph.D., J.D., University of Pittsburgh

4:00 p.m. -5:00 p.m.
Suite 2F

Auxiliary Long Range Planning Committee Meeting

Thursday, April 27, 1989

TIME/LOCATION

EVENT

7:00 a.m. -5:00 p.m.
2nd Floor Grand Hall

SCMA Registration — Open

7:00 a.m. -8:00 a.m.
Shaftesbury Room

SCMA Board of Trustees Breakfast

146

The Journal of the South Carolina Medical Association

SCHEDULE OF EVENTS

Thursday, April 27, 1989 (continued)

TIME/LOCATION

EVENT

7:00 a.m.-8:00 a.m.
Hampton Room

SCMA Past Presidents’ Breakfast

7:00 a.m. -8:00 a.m.
Colleton Room

Specialty Society Delegates Meeting

7:30 a.m. -8:30 a.m.
Booths 22 & 42

Coffee (Compliments of Physician Sales and Service, Inc.)

7:30 a.m. -5:00 p.m.
Dogwood/Cypress/Live Oak
Ballroom and Grand Hall

Exhibits Open

8:00 a.m. -9:00 a.m.
Drayton Room

Auxiliary Continental Breakfast

8:00 a.m. -5:00 p.m.
2nd Floor Lobby

Auxiliary Registration — Open

8:00 a.m. -11:30 a.m.
Willow/Magnolia Ballroom

SCMA House of Delegates

9:45 a.m. -10:45 a.m.
Booths 22 & 42

Coffee Break (Compliments of Fenwick Hall Hospital)

10:00 a.m. -11:00 a.m.
Riley Room

MUSC Medical Alumni Board Meeting

10:00 a.m.-12:00 noon
Jenkins/King Room

Auxiliary Executive Board Meeting

12:00 noon-l:30 p.m.
Gadsden Room

12:00 noon-2:00 p.m.
Colleton Room

SCMA Medical Ethics Committee and Guest Program
Participants Meeting & Luncheon

SCMA Young Physicians’ Section Luncheon & Meeting

12:30 p.m. -1:30 p.m.
Drayton Room

Reference Committee Chairmen’s Luncheon

12:30 p.m.-2:00 p.m.
Wickliffe House

Auxiliary Past Presidents’ Luncheon

12:45 p.m.-2:30 p.m.
Magnolia Ballroom

MUSC Alumni Luncheon

1:00 p.m.-2:30 p.m.
Jenkins/King Room

Risk Management Luncheon
“The Legal Noose Gets Tighter”

Harold L. Hirsh, M.D., Washington, D. C.

1:30 p.m.-3:00 p.m.
Hampton, Fenwick, Ashley
Cooper and Edmunds

SCMA Reference Committee Meetings (Specific room
assignments will appear in Delegates Handbook)

April 1989

147

SCHEDULE OF EVENTS

Thursday, April 27, 1989 (continued)

TIME/LOCATION

EVENT

2:00 p.m. -3:00 p.m.
Booths 22 & 42

Coffee Break (Compliments of CIBA)

2:00 p.m. -5:00 p.m.
Willow Ballroom

SCMA Plenary Session: “Current Concepts in the
Management of Sports Related Injuries”

“Knee Injuries for the Non-Orthopaedist”

John A. Bergfeld, M.D., The Cleveland Clinic Foundation

“LInique Sports Problems in Youth”

Suzanne Haefele, M.D., Rock Hill

“Problems in Recreational Athletes”

John A. Bergfeld, M.D., The Cleveland Clinic Foundation

3:00 p.m. -5:00 p.m.
Colleton Room

SCMA Workshop: “Common Otolaryngology/Head and Neck
Surgery Problems for the Primary Care Practitioner”

“Sinusitis: Medical Management and When to Consider
Surgery”

William R. Lomax, M.D., Summerville

“New Techniques in the Evaluation of a Neck Mass”

J. David Osguthorpe, M.D., MUSC

“How to Work-up the Dizzy Patient”

William J. Fravel, M.D., Columbia

“Current Indications for Tonsillectomy, Adenoidectomy and
P.E. Tubes”

William R. Lomax, M.D., Summerville

“Hearing Loss: What Can be Done”

Warren Y. Adkins, M.D., Charleston

“Inhalant Allergies: Diagnosis and Pharmacology”

Robert G. Mahon, Jr., M.D., Greenville

“Sleep Apnea and Snoring”

J. David Osguthorpe, M.D., MUSC

3:00 p.m. -5:00 p.m.
Drayton Room

SCMA Workshop: “How to Practice Ethical Medicine in
Today’s Financial Climate”

Nancy W. Dickey, M.D., Council on Ethical and Judicial
Affairs — AMA

3:00 p.m.-5:00 p.m. SCMA Reference Committee Meetings (Specific room

Edmunds, Ashley Cooper and assignments will appear in Delegates Handbook)

Gadsden Rooms

5:00 p.m. -6:30 p.m.
Jenkins/King Room

SCMA Young Physicians Section Reception (Compliments of
SCMA/JUA Risk Management Program)

6:00 p.m. -7:30 p.m.
Magnolia Ballroom

SCMA Reception Honoring Delegates, Alternates, Speakers
and Exhibitors

148

The Journal of the South Carolina Medical Association

SCHEDULE OF EVENTS

Thursday, April 27, 1989 (continued)

TIME/LOCATION

EVENT

6:30 p.m.-8:00 p.m.
Colleton Room

Medical College of Georgia Alumni Reception

Friday, April 28, 1989

TIME/LOCATION

EVENT

7:00 a.m.-5:00 p.m.
2nd Floor Grand Hall

SCMA Registration — Open

7:30 a. m. -8:30 a.m.
Shaftesbury Room

SCMA Board of Trustees Breakfast

7:30 a.m.-8:30 a.m.
Flagpole Terrace

Auxiliary Continental Breakfast

7:45 a.m. -8:45 a.m.
Booths 22 & 42

Coffee

8:00 a.m. -12:00 noon
2nd Floor Lobby

Auxiliary Registration — Open

8:00 a.m.-5:00 p.m.
Dogwood/Cypress/Live Oak
Ballroom and Grand Hall

Exhibits Open

8:30 a.m. -11:00 a.m.
Colleton Room

Sports Medicine Committee Breakfast Meeting

8:30 a.m. -12:00 noon
Willow Ballroom

SCMA Plenary Session: “Psychiatric Topics for Primary Care
Physicians” (Supported by a grant from the Educational ETnit
of the Upjohn Company)

“The Diagnosis and Clinical Management of Elderly
Patients”

Michael Malone, M.D., Charleston
Charles Still, M.D., Columbia

“The Psychiatric Diagnosis and Management of Depression in
Children and Adolescents’

Tillmon Simmons, M.D., Marshall I. Pickens Hospital,
Greenville

Charles Casat, M.D., MUSC

9:00 a.m. -10:30 a.m.
Gadsden Room

Prof. Liability Committee Meeting

9:00 a.m.-12:00 noon
Magnolia Ballroom

Auxiliary House of Delegates

10:30 a.m.-ll:30 a.m.
Gadsden Room

SCIMER Board Meeting

April 1989

149

SCHEDULE OF EVENTS

Friday, April 28, 1989 (continued)

TIME/LOCATION

10:30 a. m. -11:30 a.m.
Booths 22 & 42

EVENT

Coffee Break (Compliments of Charter Rivers Hospital)

12:00 noon

Golf Tournament — Organized by and Prizes Awarded by

Patriot’s Point Golf Links Mead Johnson Nutritional Division

12:00 noon-12:30 p.m.
Palmetto Courtyard

Auxiliary Reception Honoring New Officers

12:30 p.m. -2:00 p.m.
Ashley Cooper Room

S. C. Society of Ophthalmology Executive Committee
Meeting

12:30 p.m. -2:00 p.m.
Fenwick Room

Editorial Board Luncheon

12:30 p.m. -2:00 p.m.
Shaftesbury Room

Auxiliary Presidents’ Luncheon

1:00 p.m. -3:00 p.m.
Magnolia Ballroom

SCMA Workshop: “RBRVS”

James F. Rodgers, Ph.D., Director: Center for Health Policy
Research — AM A

1:00 p.m. -5:30 p.m.
Jenkins/King Room

S. C. Dermatological Association Meeting and Scientific
Session:

“Sports Dermatology”

Wilma F. Bergfeld, M.D., The Cleveland Clinic Foundation

“Sports Injuries in the Weekend Athlete”

John A. Bergfeld, M.D.? The Cleveland Clinic Foundation

“Dermatologic Therapeutic Pearls’

Richard Odom, M.D., University of California Medical
Center

“Cosmetic Drugs in Dermatology”

Wilma F. Bergfeld, M.D.

1:30 p.m. -5:00 p.m.
Drayton Room

S. C. Diabetes Association: Treatment of Diabetes Mellitus in
1989 (Supported in part by an educational grant from the
Medical Sciences Liaison, Metabolic Disease Unit of the
Upjohn Company)

Introductory Comments:

Leonard Lichtenstein, M.D.

“Aggressive Treatments for NIDDM (Type II)”

Thomas Flood, M.D., Atlanta

“Approach to Type I Patient: Improved Compliance”
Thomas Flood, M.D., Atlanta

“Gestational Diabetes, An Overview”

Kay McFarland, M.D., USC School of Medicine

150

The Journal of the South Carolina Medical Association

SCHEDULE OF EVENTS

Friday, April 28, 1989 (continued)

TIME/LOCATION

EVENT

2:00 p.m.-4:30 p.m.
Colleton Room

“Value of Experimental Immunotherapy in the Prevention of
Type I Diabetes Mellitus”

George Bright M.D., MUSC

“Clinical Approaches to the Child and Adolescent Diabetic’
Frank Bovvyer. M.D., Columbia

“The Diabetes Summer Camp Program in South Carolina
Mr. Frank Shuler, Chairman of the Board. S. C. Affiliate.
American Diabetes Association and Frank Bowyer, M.D.,
Columbia

S. C. Oncology Society Meeting and Scientific Session:
"Current Approaches to Therapy of High Grade Gliomas '

“Topographic Considerations in Therapy of Glioblastoma
Multiforme

Peter Burger, M.D., Duke University Medical Center

"Chemotherapy and Immunotherapy of Malignant Gliomas"
M. Stephen Mahalay, Jr., M.D.. Ph.D., University of Alabama
at Birmingham

“Radiotherapeutic Approaches to Glioblastoma Multiforme
Merle Salter, M.D., University of Alabama at Birmingham

2:30 p.m. -3:30 p.m.
Booths 22 & 42

Coffee Break Compliments of Boehringer Ingelheim

3:00 p.m.-5:00 p.m.
Sign up at Auxiliary
Registration Desk —
2nd Floor Lobby

Charleston Historical Tour of Physicians Homes and Gardens
with Martha Derrick and Ann Edwards

3:30 p.m. -5:00 p.m.
Hampton Room

SCMA Workshop: “AIDS and the Primary Care Physician:

S. C. Aids Training Network

Panelists: Donna L. Richter, Ed.D., University of SC; Charles
S. Bryan. M.D., USC School of Medicine: Michael Saag. M.D.,
University’ of Alabama at Birmingham School of Medicine

4:30 p.m.-6:00 p.m.
Sebring-Aimar House
C. 1840 — MUSC

MUSC Open House Continuous Shuttle Service will be
provided)

5:30 p.m.-7:30 p.m.

Home of Dr. & Mrs. A. Bert
Pruitt. Jr., 54 Meeting Street

Bowman — Gray Alumni Reception

6:00 p.m.-7:30 p.m.
Magnolia Ballroom

SCMA Reception Compliments of South Carolina Federal

April 1989

151

SCHEDULE OF EVENTS

Friday, April 28, 1989 (continued)

TIME/LOCATION

EVENT

7:00 p.m.-8:30 p.m.
Drayton Room

S. C. Neurological Association Reception

7:00 p.m.

Ashley Cooper

Hampton and Colleton Rooms
Beauregard and Edmunds
Rooms

Willow II Room
Jenkins/King Room
Willow I Room

MUSC Reunions
December Class of 1943
Class of 1944

Class of 1949
Class of 1954
Class of 1969
Class of 1974

7:00 p.m.

The Lodge Alley Inn
195 East Bay Street

MUSC Reunion — Cocktails and Dinner for Class of 1959

Saturday, April 29, 1989

TIME/LOCATION

EVENT

7:00 a. m. -5:00 p.m.
2nd Floor Grand Hall

SCMA Registration — Open

7:30 a. m. -8:30 a.m.
Shaftesbury Room

SCMA Board of Trustees Breakfast

8:00 a.m. -9:30 a.m.
Ashley Cooper Room

S. C. Chapter of the American College of Physicians
Breakfast and Business Meeting

7:45 a.m. -8:45 a.m.
Booths 22 & 42

Coffee

8:00 a.m. -12:30 p.m.
Dogwood/Cypress/Live Oak
Ballroom and Grand Hall

Exhibits Open

8:00 a.m. -9:00 a.m.
Suite 2E

S. C. Chapter of the American Academy of Pediatrics
Executive Committee Meeting

8:00 a.m. -11:00 a.m.
Hampton Room

S. C. Association of Neurological Surgeons Breakfast Meeting
and Scientific Session:

“Automated Percutaneous Diskectomy”

J. M. Marzluff, M.D., Charleston

“Surgical Treatment of Spondylolisthesis”

Stephen E. Rawe, M.D., Charleston

“New Techniques of Lumbar Spine Stabilization”

George Sypert, M.D., University of Florida Health Center

152

The Journal of the South Carolina Medical Association

SCHEDULE OF EVENTS

Saturday, April 29, 1989 (continued)

TIME/LOCATION

EVENT

9:00 a.m. -12:00 noon
Jenkins/King Room

S. C. Chapter of the American Academy of Pediatrics
Scientific Session:

“HIV Screening in Newborns”

Arthur F. DiSalvo, M.D., Columbia

“Steroid Use in Athletes”

Frank P. Bowyer, M.D., Columbia

“Public Law 99-457: Early Intervention and the Role of the
Pediatrician”

Ernest F. Krug, III, M.D., Greenville
“Pediatric AIDS”

L. Reed Shirley, M.D., Children’s Hospital, Charleston

8:00 a.m. -12:00 noon
MUSC, Basic Science Building

S. C. Society of Anesthesiology: Pediatric Anesthesia

“Pediatric Outpatient Anesthesia”

Norman Brahen, M.D., MUSC

“Do Neonates Need Anesthesia?”

Andy Stacik, M.D., USC School of Medicine

“Regional Anesthesia to Infants and Children”

Chris Yeakel, M.D., USC School of Medicine

8:30 a.m. -12:00 noon
Willow Ballroom

SCMA Plenary Session: Occupational and Environmental
Health

“Overview”

David E. Koon, M.D., Columbia

“Occupational Dermatoses”

Edward J. Shmunes, M.D., Columbia

“The Role of the Industrial Hygenist”

Richard Bennett, Ph.D., Azimuth, Inc., Charleston

8:30 a.m. -12:00 noon
Gadsden Room

S. C. Neurological Association

“Neurologists and the RBRVS

Nelson G. Richards, M.D., Richmond, VA

8:30 a.m. -12:30 p.m.
Colleton Room

S. C. Dermatological Association Meeting and Scientific
Session:

“The Art of Chemical Peeling”

Harold J. Brody, M.D., Atlanta

“Dermatologic Manifestations of HIV Infection”
Richard Odom, M.D., University of California Medical
Center

“What’s New”

Bruce H. Thiers, M.D., MUSC

9:00 a.m. -11:00 a.m.
Edmunds Room
April 1989

SOCPAC Board Meeting

153

SCHEDULE OF EVENTS

Saturday, April 29, 1989 (continued)

TIME/LOCATION

EVENT

9:00 a. m. -12:15 p.m.
Drayton Room

S. C. Radiological Society Meeting and Scientific Session:

“The Importance of New Technology for Radiology”

Ronald G. Evens, M.D., Mallinckrodt Institute of Radiology

“Ultrasonography of the Newborn”

Michael S. Tenner, M.D., New York Medical College

“3-D Computed Tonography”

Richard Holgate, M.D., MUSC

“Relative Value Scale for Radiologists and Current Situation
with HCFA

Robert S. Lackey, M.D., Charlotte, N. C.

10:00 a. m. -11:00 a.m.
Booths 22 & 42

Coffee Break (Compliments of Shepherd Spinal Center)

10:00 a.m. -12:00 noon
Suite 2]

S. C. Society of Pathologists Business Meeting

11:00 a.m.

MUSC Reunion — Brunch for Class of 1964

Home of Dr. & Mrs. Bonner
Thomason

12:15 p.m. -1:15 p.m.
Shaftesbury Room

S. C. Radiological Society Reception

12:45 p.m. -2:15 p.m.
Magnolia Ballroom

SOCPAC Luncheon

Guest Speaker: John S. Zapp, D.D.S., Director of Government
Affairs — AMA, Washington, D. C.

1:00 p.m. -6:00 p.m.
Jenkins/King Room

S. C. Chapter, American Academy of Family Physicians
Board Meeting

1:15 p.m. -3:45 p.m.
Shaftesbury Room

S. C. Radiological Society Luncheon and Meeting

1:30 p.m. -3:00 p.m.
Edmunds Room

SCMA Workshop: “The Geriatrics Patient”

“Management of Pressure Sores in the Nursing Home
Environment”

David Stokes, M.D., Inman

“Rheumatic Diseases in the Geriatric Population”
Richard M. Silver, M.D., MUSC

2:00 p.m. -4:00 p.m.
Colleton Room

S. C. Society of Pathologists Scientific Session: “Soft Tissue
Pathology”

Franz Enzinger, M.D., Washington, D. C.

2:30 p.m. -4:30 p.m.
Willow Ballroom

S. C. Cardiac Rehabilitation Association Meeting

“Cardiac Rehabilitation: Direction for the Nineties”
John Cantwell, M.D.

154

The Journal of the South Carolina Medical Association

SCHEDULE OF EVENTS

Saturday, April 29, 1989 (continued)

TIME/LOCATION

EVENT

2:30 p.m.-5:00 p.m.
Drayton Room

CLE/CME

3:00 p.m. -4:30 p.m.
Hampton Room

Annual Meeting of the South Carolina Medical Care
Foundation and Board of Directors

6:30 p.m.-7:30 p.m.
Dogwood/Cvpress Ballroom

SCMA Presidents’ Reception (Compliments of Carolina
Physicians Advisory Service)

7:00 p.m.

The Fish Market
12 Cumberland at East Bay

MUSC Reunion — Dinner for Class of 1964

7:30 p.m.-12:00 a.m.

SCMA President’s Inaugural Banquet (Dancing and Open

Willow Magnolia and Live Oak Bar — Compliments of the S. C. Medical Care Foundation)
Ballrooms

Sunday, April 30, 1989

TIME/LOCATION

EVENT

7:00 a.m.-10:30 a.m.
2nd Floor Grand Hall

SCMA Registration — Open

7:30 a.m. -8:30 a.m.
Shaftesbury Room

SCMA Board of Trustees Breakfast

8:30 a.m. -12:30 p.m.
Dogwood/Cypress and Live
Oak Ballrooms

SCMA House of Delegates

12:30 p.m.-l:00 p.m.
Jenkins King Room

SCMA Board of Trustees Reorganization Meeting

April 1989

155

YOCON'

YOHIMBINE HCI

CKrafate

^-^(sucralfate) Tablets

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.

Indications: Yocon® is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.12 Also dizziness,
headache, skin flushing reported when used orally.13
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence.1 '34 1 tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to Vi tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of Yocon® 1/12 gr. 5.4 mg in

AVAILABLE EXCLUSIVELY FROM

bottles of 100's NDC 53159-001-01 and 1000’s NDC

53159-001-10.

References:

1. A. Morales et al. , New England Journal of Medi-
cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed., p. 176-188.

McMillan December Rev. 1/85.

3. Weekly Urological Clinical letter, 27:2, July 4,

1983.

4. A. Morales et al. , The Journal of Urology 1 28:

45-47, 1982.

Rev. 1/85

PALISADES

PHARMACEUTICALS, INC.

219 County Road
Tenafly, New Jersey 07670
(201) 569-8502
1-800-237-9083

BRIEF SUMMARY

CONTRAINDICATIONS

There are no known contraindications to the use of sucralfate.

PRECAUTIONS

Pregnancy: Teratogenic effects. Pregnancy Category B. Teratogenicity
studies have been performed in mice, rats, and rabbits at doses up to 50 times
the human dose and have revealed no evidence of harm to the fetus due to
sucralfate. There are, however no adequate and well-controlled studies in
pregnant women. Because animal reproduction studies are not always pre-
dictive of human response, this drug should be used during pregnancy only if
clearly needed.

Pediatric Use: Safety and effectiveness in children have not been
established.

ADVERSE REACTIONS

OVERDOSAGE

There is no experience in humans with overdosage. Acute oral toxicity studies
in animals, however; using doses up to 1 2 gm/kg body weight could not find a
lethal dose. Risks associated with overdosage should, therefore, be minimal

DOSAGE AND ADMINISTRATION

The recommended adult oral dosage for duodenal ulcer is 1 gm four times a
day on an empty stomach.

Antacids may be prescribed as needed for relief of pain but should not be
taken within one-half hour before or after sucralfate.

While healing with sucralfate may occur during the first week or two,
treatment should be continued for 4 to 8 weeks unless healing has been
demonstrated by x-ray or endoscopic examination.

HOW SUPPLIED

CARAFATE (sucralfate) 1-gm tablets are supplied in bottles of 100 (NDC
0088-1712-47) and in Unit Dose Identification Paks of 100 (NDC 0088- 1712-49)
Light pink scored oblong tablets are embossed with CARAFATE on one side
and 1712 bracketed by C's on the other. Issued 1/87

Reference:

1 . Eliakim R, Ophir M, Rachmilewitz D: J Clin Gastroenterol 1 987;9(4):395-399.

CAFAD276

Another patient benefit product from

PHARMACEUTICAL DIVISION

MARION

LABORATORIES. INC.
KANSAS CITY. MO 6A137

0160N8

1989 DELEGATES AND ALTERNATES

ABBEVILLE

Alternate:

AIKEN

ALLENDALE

Alternate:

ANDERSON

Alternates:

BAMBERG

Alternate:

BARNWELL

Alternate:

BEAUFORT

BERKELEY

CHARLESTON

Alternates:

Robert Todd, M.D.

Albert G. Oliver, M.D.
William L. Meehan, M.D.
Jack L. Ratliff, M.D.

Randy D. Watson, M.D.
Thomas B. Warren, Jr., M.D.
Hunter E. Woodall, M.D.
Len W. Douglas, Jr., M.D.
Rebecca Fore, , M.D.

Daniel Koontz, M.D.

John B. Martin, M.D.
Kenneth Smith, M.D.

Clifford W. Straughn, M.D.
Daniel Fleming, M.D.

John R. Hunt, M.D.

Vernon Merchant, M.D.
Marion Dwight, M.D.

Joseph Thomas, M.D.

Henry Gibson, M.D.

Mir Khan, M.D.

John T. Brennan, M.D.
Oswald L. Mikel, M.D.

H. Timberlake Pearce, M.D.
Samuel O. Schumann, M.D.
Albert F. Aiken, M.D.

Walter Bonner, Jr., M.D.
Randolph Bradham, M.D.
Robert Cathcart, III,, M.D.
Walton Ector, M.D.

Clay W. Evatt, Jr., M.D.

Alan Fogle, M.D.

Charles Geer, M.D.

Thomas Harper, III, M.D.
Samuel E. Hazell, M.D.
Thomas M. Leland, M.D.

I. Grier Linton, Jr., M.D.
Thomas Lucas, M.D.

George Malanos, M.D.

R. Ramsey Mellette. M.D.
Margaret M. Metcalf, M.D.
William Middleton, M.D.
Roy E. Nickles, M.D.

H. Biemann Othersen, M.D.
Ralph F. Principe. M.D.
Daniel Ravenel, M.D.

Eugene Rutland, M.D.
Robert M. Sade, M.D.

Don A. Schweiger. M.D.
Richard Elmer, M.D.

Gilbert Baldwin, M.D.
Bertram Finch, M.D.

Michael Hull, M.D.

Bright McConnell, M.D.
Rhett McCraw, M.D.

Alan Nussbaum, M.D.

Allan Rashford, M.D.
William Rambo, M.D.
Edmund Rhett, Jr.. M.D.

CHEROKEE

Alternate:

CHESTER

CHESTERFIELD

Alternate:

COLLETON

Alternates:

COLUMBIA

Alternates:

DARLINGTON

Alternate:

DILLON

Alternate:

DORCHESTER

Alternates:

EDISTO

Alternates:

FAIRFIELD

FLORENCE

Jay Hammett, M.D.

M. Jane Wasson, M.D.

Richard P. Hughes, M.D.
Samuel Stone, M.D.

Winston Y. Godwin, M.D.
James Thrailkill, M.D.

J. Frank Biggers, M.D.

Joseph Flowers, M.D.

Riddick Ackerman, M.D.
Samuel Wood, M.D.

M. Donald Alexander, M.D.
William H. Babcock. M.D.
O’Neill Barrett, Jr., M.D.

Eloise A. Bradham, M.D.

Alan Brill, M.D.

Belton Caughman, M.D.
Ronald L. Collins, M.D.

Janice Coleman, M.D.

Everett L. Dargan, M.D.
Jerome Davis, M.D.

Pierre Jaffee, M.D.

James Haynes, M.D.

R. Gregors Jowers, M.D.
Edward Kimbrough. Ill,, M.D.
James A. McFarland, M.D.
Thomas W. Messervy, M.D.
Robert N. Milling, M.D.
Herbert B. Niestat, M.D.

Ben Paysinger, M.D.

John C. Rawl, M.D.

Leslie W. Shelton, M.D.

John Ward, M.D.

C. Tucker Weston, M.D.

Jack H. Gottlieb, M.D.

Richard Allison, III, M.D.
Robert Clark, M.D.

Lee Jordan, M.D.

W. Rion Dixon, M.D.

Morrison Farish, M.D.

G. S. Connor, M.D.

Rufus H. Cain, M.D.

Swift Black, M.D.

Thomas R. Bolt, M.D.

Michael Edwards, M.D.

Walter Leventhal, M.D.

J. Gavin Appleby, M.D.

Gary Fink, M.D.

M. S. Funderburk, Jr., M.D.
Michael Hay, M.D.

Boyce Lawton, M.D.

Robert Smoak, M.D.

G. A. Delaney, M.D.

James Hudson, M.D.

Anil J. Kudchadkar, M.D.
Marion Carr, Jr., M.D.

Al Dawson, M.D.

James D. Hammond. Jr., M.D.
Sompong Kraikit, M.D.

Berry B. Monroe, M.D.

April 1989

161

1989 DELEGATES

Steven R. Ross, M.D.

Bruce White, M.D.

Alternates:

George Dawson, III, M.D.
Edward Lee, M.D.

GEORGETOWN

Gerald E. Harmon, M.D.
Michael E. Reed, M.D.

GREENVILLE

Joy S. Anglea, M.D.

William P. Bonner, M.D.
Norris I. Boone, M.D.
Raymond E. Bradley, M.D.
Wayne C. Brady, M.D.
Duncan Burnette, Jr., M.D.
William Evins, M.D.
Lawrence Hartley, M.D.
Sella R. Littlepage, M.D.

P. Irvine Lupo, M.D.

Joseph McAlhany, M.D.
Arthur G. Meakin, M.D.
Darius Ornston, M.D.

David Potts, M.D.

William W. Pryor, M.D.
William G. Rhea, M.D.
Daggett 0. Royals, M.D.
John R. Satterthwaite, M.D.
Pam S. Snape, M.D.

Joseph H. Wentzky, M.D.

Alternate:

Ted J. Roper, M.D.

GREENWOOD

Grover Henderson, M.D.
Julius Leary, M.D.

0. T. Willard, M.D.

HAMPTON

Count Pulaski, Jr., M.D.

Alternate:

Harrison Peeples, M.D.

HORRY

Reginald F. Daves, M.D.
Daniel M. Ervin, M.D.

J. Stewart Haskin, M.D.
John D. Thomas, Jr., M.D.
Thomas A. Whitaker, M.D.
Eston E. Williams, Jr., M.D.
James W. Yates, Jr., M.D.

Alternates:

Calhoun Cunningham, M.D.
Susan J. Haskin, M.D.

JASPER

J. M. Bennett, Jr., M.D.

Alternate:

John O. Ryan, M.D.

KERSHAW

Not Available at Press Time

LANCASTER

Fred Kimbrell, M.D.
Helen Llewelyn, M.D.

LAURENS

Holbrook W. Raynal, M.D.

Alternate:

R. W. Watkins, M.D.

LEXINGTON

Franklin L. Clark, M.D.
Charles F. Crews, M.D.
Robert Galphin, Jr., M.D.
Bryan L. Walker, M.D.

J. D. Whitehead, M.D.

Alternate:

James L. Hahn, M.D.

MARION

Hugh V. Coleman, M.D.
James Garner, IV, M.D.

Alternates:

James Suggs, M.D.
Robert Ziff, M.D.

MARLBORO

James McAlpine, M.D.

Alternate:

Church Whitner, M.D.

NEWBERRY

John H. Ferguson, M.D.
Joel S. Sexton, M.D.

AND ALTERNATES

OCONEE

Julius R. Earle, M.D.
Conrad Shuler, II, M.D.

Alternates:

Edward H. Booker, M.D.
James R. Pruitt, M.D.

PICKENS

Rhett David, M.D.
Calvin Snipes, M.D.
Boyce Tollison, M.D.

RIDGE

Benjamin E. Nicholson, M.D.

Alternate:

Hugh Morgan, M.D.

SPARTANBURG

George Blestel, M.D.

Ernest Camp, III, M.D.

W. M. Davis, M.D.

Robert E. Flandry, M.D.
Gordon France, M.D.
Elwyn James, M.D.
Timothy Llewelyn, M.D.
Thomas McLeod, M.D.
John Nichols, M.D.

Thomas L. Robinson, M.D.
James Story, M.D.

H. Al Stresing, M.D.

Tom Westmoreland, M.D.
Auburn Woods, M.D.

Alternates:

David Berry, M.D.

Paul D. Bunn, M.D.
John E. Keith, Jr., M.D.

SUMTER-

Linwood G. Bradford, M.D.

CLARENDON-

Allan P. Bruner, M.D.

LEE

J. Capers Hiott, M.D.
James R. Ingram, M.D.

UNION

William J. Stamper, M.D.

Alternate:

Harold P. Hope, M.D.

WILLIAMSBURG

Howard H. Poston, M.D.

Alternate:

Frank Trefny, M.D.

YORK

Rion Rutledge, M.D.
George White, M.D.

Alternate:

Luke Lentz, M.D.

S. C. SOCIETY FOR ALLERGY & CLINICAL
IMMUNOLOGY
Not Available at Press Time
S. C. SOCIETY OF ANESTHESIOLOGISTS
John E. Mahaffey, M.D.

Alternate: Laurie Brown, M.D.

S. C. CARDIAC & THORACIC SURGICAL SOCIETY
R. Randoph Bradham, M.D.

Alternate: James E. May, M.D.

S. C. DERMATOLOGICAL ASSOCIATION
Kenneth R. Warrick, M.D.

Alternate: Sam Stafford, M.D.

S. C. CHAPTER, AMERICAN COLLEGE OF
EMERGENCY PHYSICIANS
Robert Malanuk, M.D.

S. C. ACADEMY OF FAMILY PHYSICIANS
William Hester, M.D.

Alternate: Stoney Abercrombie, M.D.

S. C. INTERNAL MEDICINE SOCIETY
George Malanos, M.D.

S. C. ASSOCIATION OF NEUROLOGICAL SURGEONS
Bartolo Barone, M.D.

Alternate: Darwin Kelly, M.D.

S. C. NEUROLOGICAL ASSOCIATION
Albert F. Aiken, M.D.

162

The Journal of the South Carolina Medical Association

1989 DELEGATES AND ALTERNATES

S. C. OB/GYN SOCIETY
Guy Meares, Jr., M.D.

Alternate: Robert Lumpkin, M.D.

S. C. ONCOLOGY SOCIETY
Not Available at Press Time
S. C. SOCIETY OF OPHTHALMOLOGY
Michael Tapert, M.D.

S. C. ORTHOPEDIC ASSOCIATION
Lawrence P. Brown, M.D.

Alternate: Frederick Reed, M.D.

S. C. SOCIETY OF OTOLARYNGOLOGY, HEAD AND
NECK SURGERY
David Osguthorpe, M.D.

Alternate: Robert Mahon, M.D.

S. C. SOCIETY OF PATHOLOGISTS
Hans Habermeier, M.D.

Alternate: William Crymes, M.D.

S. C. CHAPTER OF AMERICAN ACADEMY OF
PEDIATRICIANS AND THE S. C. PEDIATRIC
SOCIETY

Francis Rushton, M.D.

Alternate: Thomas Gue, M.D.

S. C. SOCIETY OF PLASTIC & RECONSTRUCTIVE
SURGEONS

Not Available at Press Time
S. C. PHYSICAL MEDICINE & REHABILITATION
Robert G. Schwartz, M.D.

Alternate: Jim Warmoth, M.D.

S. C. PSYCHIATRIC ASSOCIATION
Roy Ellison, M.D.

Alternate: Richard Harding, M.D.

S. C. RADIOLOGY SOCIETY
H. Woodliff Sanford, M.D.

Alternate: Charles Griffin, M.D.

S. C. CHAPTER OF THE AMERICAN COLLEGE OF
SURGEONS

Not Available at Press Time
S. C. SURGICAL SOCIETY
William J. Goudelock, M.D.

S. C. THORACIC SOCIETY
Charles White, Jr., M.D.

S. C. UROLOGICAL ASSOCIATION
George DelPorto, M.D.

S. C. VASCULAR SURGICAL SOCIETY
Not Available at Press Time
YOUNG PHYSICIANS SECTION
Roger Gaddy, M.D.

Alternate: Steve Hulecki, M.D.

COMPONENT UNIT OF HOUSE STAFF PHYSICIANS
Lisa Bryant, M.D.

March Seabrook, M.D.

MEDICAL UNIVERSITY OF SOUTH CAROLINA,
DEAN, COLLEGE OF MEDICINE

UNIVERSITY OF SOUTH CAROLINA, DEAN, SCHOOL
OF MEDICINE
J. O’Neal Humphries, M.D.

MUSC MEDICAL STUDENT SECTION PRESIDENT
Robert Mingus

USC MEDICAL STUDENT SECTION PRESIDENT
Mike Avant

PARLIMENTARIAN
James M. Long, III, M.D.

SPEAKER OF THE HOUSE OF DELEGATES
O. Marion Burton, M.D.

VICE SPEAKER OF THE HOUSE OF DELEGATES
Benjamin E. Nicholson, M.D.

TWO IMMEDIATE PAST PRESIDENTS
Charles R. Duncan, Jr., M.D.

Walter J. Roberts, Jr., M.D.

PHYSICIAN MEMBER OF THE BOARD OF
DEPARTMENT OF HEALTH AND
ENVIRONMENTAL CONTROL
Euta M. Colvin, M.D.

PRESIDENT OF BOARD OF MEDICAL EXAMINERS
J. Ernest Lathem, M.D.

AMA DELEGATES
John C. Hawk, Jr., M.D.

Donald G. Kilgore, Jr., M.D.

Randolph D. Smoak, Jr., M.D.

AMA ALTERNATE DELEGATES
Charles R. Duncan, Jr., M.D.

Walter J. Roberts, Jr., M.D.

J. Gavin Appleby, M.D.

SCMA BOARD OF TRUSTEES
Thomas C. Rowland, Jr., M.D., President
Daniel W. Brake, M.D., President-Elect
Bartolo M. Barone, M.D., Treasurer
Carol S. Nichols, M.D., Secretary
J. Chris Hawk, III, M.D., Trustee, First District, Board
Chairman

John B. Johnston, M.D., Trustee, First District
Edward W. Catalano, M.D., Trustee, Second District,
Vice Chairman of Board
Frank W. Young, M.D., Trustee, Second District
Richard M. Carter, M.D., Trustee, Third District
James B. Page, M.D., Trustee, Fourth District
William J. Goudelock, M.D., Trustee, Fourth District
Terry L. Dodge, M.D., Trustee, Fifth District
James M. Lindsey, Jr., M.D., Trustee, Sixth District Clerk
Stephen A. Imbeau, M.D., Trustee, Sixth District
S. Perry Davis, M.D., Trustee, Seventh District
John W. Rheney, Jr., M.D., Trustee, Eighth District
John W. Simmons, M.D., Trustee, Ninth District
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April 1989

163

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OFFICER REPORTS

THE PRESIDENT

Thank you for the privilege of serving as your
president this past year. SCMA is in good condi-
tion and has had a very successful and productive
year. Organized medicine has served its constitu-
ent members, in fact, all the physicians in South
Carolina as well as the citizens of South Carolina,
in an exemplary manner. It has been a busy year
for your president. I will try to summarize my
activities succinctly in this report.

On the national scene, I have attended two very
important AMA meetings. At the Annual Meeting
in June, the resolution concerning registered care
technologists was passed by the AMA House of
Delegates. This created quite a stir among orga-
nized nursing. In the interim AMA meeting, the
Resource Based Relative Value Scale was debated
and endorsed to the degree that AMA will partici-
pate as a major player in its development. Both of
these are issues very important to the continued
private practice of medicine on a fee for service
basis. I attended and was appointed chairman of a
discussion group with a national conference of
Blue Cross executives and leaders in medicine.
This was a very good meeting and should result in
an improved relationship between physicians and
"the blues.” Hopefully we can develop some ad-
visory relationship with Blue Cross and Blue
Shield of S. C.

SCMA has developed a very strong position on
the S. C. legislative scene. Our legislative efforts
have been tremendously successful. Xot a single
bill that we opposed in the 1988 Session got out of
committee! Finally, SCMA is dealing with a pro-
active philosophy which is much more rewarding
in the legislature than retroactive reaction. We
have gained the respect of a large number of
members of both Houses, and I predict our con-
tinued success in the current session.

I have enjoyed a very good relationship with
Commissioner Mike Jarrett of DHEC. I have
served as a consultant and as a member of his ad
hoc committee to improve maternal and child
health. We are headed in a positive direction on
this front. As a consultant to the Health and
Human Services Finance Commission, I have had
the opportunity to represent SCMA on the Medi-
caid front. Dr. Andy Laurent has accepted and
responded to SCMA input concerning the Medi-

caid program in South Carolina. I encourage you
all to participate in this very necessary part of our
medical delivery system. SCMA and Dr. Laurent
are trying to join in an effort to make the system
more palatable.

It seems that some progress is being made in the
waste disposal issue. With all the publicity of
dumped medical waste showing up on our
beaches last summer, we are now faced with the
issue of infectious waste disposal. Hopefully, we
can resolve this issue comfortably in the present
legislative session.

One of my real thrusts this year was to try to get
some good news out to the public about our asso-
ciation and our profession. I have enjoyed a very
good relationship with the news media this year. I
have been consulted on every newsworthy issue,
and I believe we have prevailed in most instances.
I must say that the media representatives have
certainly treated me fairly and honestly.

The Personal Care physician program is under
way and has brought positive comments from
members of the Legislature and the media. I
encourage all our membership who are not par-
ticipating physicians in Medicare to join this pro-
gram. The Personnel Care program demands
little extra from you and provides a real service to
the need}' elderly and a boost to our public ap-
pearance. This program can reward the profes-
sion in good will which we sorely need.

SOCPAC and AMP AC continue to flourish. For
the first time ever we have more than a thousand
members in SOCPAC. This still represents only
about one-third of our membership. We should
have 100% membership in SOCPAC and even this
would be "a drop in the bucket” compared to
what some of our adversaries are spending. Four
hundred seventeen chiropractors in S. C. have
employed a former state senator, a very im-
pressive and expensive Columbia P.R. firm and a
law firm in Columbia to represent them — and
only a third of our members will spend $100 to
join SOCPAC. Think about that! SOCPAC has
been very effective in the local state political
campaigns. I am sure you have heard the John
Rama story. In fact, only one or two SOCPAC
supported candidates lost their elections last year.
SCMA enjoys a respectable fifth in the nation in

April 1989

167

OFFICER REPORTS

percent of members in AMPAC.

The SCMA Auxiliary has been very active this
year, under the capable leadership of Mrs. Mary
James. The Health Education Van is launched
and is a very positive addition to health education
in South Carolina. The S. C. Department of Edu-
cation has accepted its maintenance and staffed it
with two very capable health educators. The aux-
iliary is to be commended for this very successful
project which will serve a great need in S. C. We
are the first state to have such a project and will
surely get recognition for it at the national level. I
thank the auxiliary and especially Mary James for
their support during the past year.

As usual, the committee chairmen and mem-
bers who have served this year have done a yeo-
man’s job. The productivity of our association
depends on the committee structure. I sincerely
thank all of you for your time, your thoughts and
your loyalty to SCMA. I have tried to involve more
and more members in the work of the association.
I have especially tried to identify and involve
interested younger physicians. Those who have
become involved have recognized the need and
purpose of SCMA and will be its future leaders.

I am very grateful to all of our component
county medical societies. Your interest and sup-
port provide SCMA with a grass roots system
second to none. I have certainly enjoyed the hospi-
tality and camaraderie of the county societies that
I have visited. I am very sorry that I was unable to
visit you all. I hope I was able to share some
information and impart some enthusiasm for or-
ganized medicine to each of you. I frequently
hear the locker room discussions of how little we
do, but I hope I have been able to shed some light
on how much we are doing for all of our
membership.

The AMA Delegation has worked hard for us at
the national level. Dr. Hawk (Jr.) is a real task-
master who sees to it that all in attendance partici-
pate in reference committees and are well read on
the issues. We have a dedicated, hard working
delegation who represent us well.

The SCMA Annual Meeting has become a truly
outstanding event. Dr. Marion Burton has han-
dled the business of our House of Delegates in a
very professional manner. Having visited other
state meetings this year, I can honestly say we are
better than most. Dr. O’Neill Barrett is to be
commended on his performance as our CME pro-
gram director. His scientific programs for the last

168

few years are truly a class act! We have continued
increases in attendance and are even attracting
out-of-state physicians. One could not expect a
better weekend with old professional friends.

The President’s Page in the SCMA Journal has
been a fantastic outlet for some of my philosoph-
ical thoughts. I have really enjoyed the oppor-
tunity to say what I thought on a few subjects. I
have been criticized for some and praised for
some, as it should be, from individual members. I
was very flattered to have had one of my ’pages’
faxed to all state associations by the AMA. My
invitations to speak to the Charleston Downtown
Rotary Club, the Sumter Rotary Club, the Na-
tional Association of JUA’s, and many other
groups were very flattering, and I hope that I
represented you well before these groups.

The staff of the SCMA is fantastic! The staff
members are well coordinated, and I have not
heard an unpleasantry from the home office. I
could not have had better support. Bill Mahon has
far exceeded his job description in helping me to
provide leadership for SCMA. I would like to
thank and commend each of the staff for their
tireless efforts and loyalty to our organization. In
all my years of involvement, I have never wit-
nessed a more pleasant and supportive group.

Dr. Chris Hawk has done a tremendous job as
Chairman of the Board of Trustees. He has
streamlined the meetings, making them much
more efficient and productive. I am sure all our
board members appreciate his very capable lead-
ership. I thank the members of the SCMA Board
of Trustees for all your support and help through
the year. You have all worked very hard to make
the SCMA productive and successful in its mission
during the year.

In summary, the SCMA has had a very suc-
cessful year from the viewpoint of your president.
I truly appreciate your trust and confidence in
allowing me to preside. It is truly the greatest
honor I have realized in life. As I turn the gavel
over to Dr. Dan Brake, I commend him to you as a
thoroughly attractive and intelligent leader and
friend who will serve us well and to whom I
pledge my loyal support.

Respectfully submitted,

Thomas C. Rowland, Jr., M.D.,

President

The Journal of the South Carolina Medical Association

OFFICER REPORTS

THE SPEAKER OF THE HOUSE

The 141st Annual Meeting and Scientific As-
sembly of the SCMA will be held April 26-30,
1989. in the Omni Hotel at Charleston Place. This
is the third year our meeting will be held in this
charming setting. That should add excitement
and enthusiasm to the scientific sessions and social
events. O’Neill Barrett, M.D., once again has an
outstanding array of academic and clinical talent
assembled to update us in various aspects of medi-
cine. Nancy Dickey, M.D., will present our third
annual Leonard Douglas Memorial Lecture at the
Thursday morning House of Delegates. We will
be privileged to have Dr. John Clowe, Speaker of
the AMA House of Delegates, with us for the
weekend. In addition to the scientific assemblies,
there will be major sessions on the Harvard Rela-
tive Value Scale and Ethics. Please make your
plans to share all this and more with us in
Charleston.

Your Board of Trustees, officers and staff have
worked this year to implement those resolutions
and recommendations adopted by the House of
Delegates at its 1988 meeting and included in this
report. You accepted a recommendation by the
Trustee from the First Medical District that Board
of Trustees’ minutes be summarized and included
in the “SCMA Newsletter. ” This has been accom-
plished, and the result is a more timely involved
membership between annual meetings. Your vote
last year for an increase in dues has resulted in
continued financial stability and strength of our
organization. Without appropriate financing,
your staff and officers could not have ac-
complished many of the victories you and your
patients have witnessed this year. Your reaffirma-
tion of concern about toxic waste in this state has
helped prompt our governor, legislators, involved
agencies and the press to implement strong lan-
guage regarding the continued movement of toxic
and hazardous waste to S. C. for storage. Governor
Campbell has issued an executive order banning
these substances from entering S. C. from states
who do not allow storage of these materials them-
selves. DHEC has strengthened its approach to
these storage sites and involved your SCMA lead-
ership in their task force. We have gone on record
as recognizing the potential hazards of tanning
facilities. Your 1988 House of Delegates adopted
an official position regarding patients with AIDS.
Evidence of your 1987 actions regarding tort re-

form are being felt in stable and in some cases
lower professional liability insurance premiums.
The Personal Care program for Medicare indi-
viduals has been widely acclaimed by laymen and
influential legislators, clearly eliminating the
need for any mandatory assignment. Your resolu-
tion F-9 asking you, the staff and officers to seek
means to have the current PRO replaced has been
successful. We now have a new professional re-
view agency in this state.

As you peruse the resolutions from last year and
listen to various staff and officer reports including
that of our Executive Wee President, you will
undoubtedly see that the directions you set for our
association resulted in numerous successes this
past year.

Your staff continues to work to insure that the
House of Delegates functions as a completely
representative body for our membership. We
have had an increased interest in our body from
the specialty society delegate representation this
year and this is particularly pleasing. We want to
continue to enhance the spontaneity and effec-
tiveness of our body and to enhance the oppor-
tunity for individual delegate input. In these and
other matters we owe a debt of gratitude to our
Executive Vice President, Bill Mahon, and the
staff that serves us so well. Day in and day out,
through many difficult negotiations, plans and
activities, these men and women are guarding our
interests and those of our patients. When you see
them, don’t forget to thank them for what they do
for us.

Respectfully submitted,

O. Marion Burton, M.D.,

Speaker of the House

THE TREASURER

As I complete my second year as Treasurer of
the South Carolina Medical Association, I would
like to present a short report about the SCMA’s
financial condition. A more comprehensive report
will be presented to the 1989 House of Delegates
in Charleston.

For the year ended June 30, 1988, the SCMA
had net expenses over revenue including de-
preciation of $122,841. However, if you exclude
depreciation expense of $29,531 the SCMA had
net operating expenses over revenue of $93,310.

April 1989

169

OFFICER REPORTS

The SCMA had a Fund Balance of $1,487,010 as
of June 30, 1988.

The SCMA’s current financial condition for the
seven months ended January 1989 projects a nega-
tive financial position. At the end of January, the
SCMA had expenses over revenue of $75,243. We
currently project that the SCMA will have net
expenses over revenue of $100,000 for this fiscal
year.

The investment policies of the SCMA and its
affiliates have continued in a similar manner, as in
past years, with diversified investments in federal
treasury and agency notes and money market
funds. As of June 30, 1988, the SCMA’s permanent
and operating reserves had balances of $1,100,000
and $387,010 respectively.

It is the SCMA’s policy to maintain total re-
serves equal to one year’s operating budget and
any excess should be allocated to cover future
operational deficits. Therefore, the permanent

THE CHAIRMAN OF THE BOARD

Thank you Mr. Speaker, members of the House
of Delegates, members of the SCMA, and guests.
Each year the chairman reports that the board has
been very active, and this year was no exception.
The board’s responsibility is to carry out the direc-
tives of the House of Delegates, to set board oper-
ating and program policies for the SCMA, to
monitor achievement of goals and objectives, and
to evaluate SCMA programs to determine if they
meet the needs of its members. I think that the
board is effectively handling its responsibility, but
I submit that the task is great, and we would
benefit from your input at any time.

At its regular meetings, the board or Executive
Committee approves honorary and disabled
memberships, approves appointments to SCMA
committees and subsidiary boards, selects nomi-
nees for state government commissions and de-
partments, reviews the financial reports of the
SCMA and its subsidiaries, reviews the mem-
bership totals and discusses ways to increase mem-
bership, and evaluates and handles requests from
individual members or component societies. The
board regularly refers items to the SCMA commit-
tees. However, most of the time at board meetings
is not spent on these routine tasks, but rather in
discussing the major issues which are facing the
SCMA and its members.

170

and operating reserves will remain constant for
the year ending June 30, 1989.

The House of Delegates in 1988 approved a
dues increase of $100 which will be implemented
over a period of three (3) years. This will be the
first dues increase since 1977, which is a consider-
able accomplishment in itself and one of which we
should be proud. We have a record of operating
on a sound financial basis and with this increase
we will continue to do so. For fiscal year ending
June 1990 we project a loss of approximately
$80,000; however, the following year we should
have a balanced budget. I thank the membership
for the privilege of having served as your treasurer
for this past year.

Respectfully submitted,

Bartolo Barone, M.D., F.A.C.S.,
Treasurer

The Chairman of the Board is elected at a
Board Reorganization Meeting at the conclusion
of the SCMA Annual Meeting. I thought that I
would have a few months to learn the ropes, but
unfortunately our Medicare carrier (Blue Cross)
dropped a major bombshell when it mailed 4,500
Prohibition Against Billing Notices (“Medically
Unnecessary’’ letters) the following day! Like
most physicians, I did not know how to decipher
these letters, much less what to do about them.
The SCMA staff immediately contacted AMA and
Blue Cross, realized that Blue Cross had made
some major errors, and convinced them not to
send out any more notices until the situation had
been clarified. Blue Cross had been sending out
these letters based on a computer screen, rather
than following the HCFA policy to carry out
“claims development” first. The board voted to
take a strong stand on this issue by demanding that
Blue Cross rescind its original letter and send an
apology to physicians and patients. Blue Cross
complied with our request. We also sent a letter to
Otis Bowen, M.D., Secretary of U. S. Department
of Health and Human Services, and made sug-
gestions for appropriate implementation of the
law.

On June 20th the SCMA staff, Dan Brake, and I
met with representatives from Blue Cross and our

The Journal of the South Carolina Medical Association

OFFICER REPORTS

Congressmen to discuss the situation. All the Con-
gressmen had received numerous complaints
from physicians in their districts and were very
receptive to our requests for their help. During
the next month the SCMA staff worked with the
Rlue Cross staff to ensure that they were following
the proper procedure before sending out Medi-
care PAB Notices. During the entire period the
SCMA kept the membership informed through
direct mail and timely updates in The Journal.

The board wrote our Congressmen, asking
them to contact HCFA expressing our dissatisfac-
tion with implementation of the law and recom-
mending that a minimum dollar cut-off be
established (e.g. $25), below which PAB Notices
would not be sent. In July the board sent a second
letter to our Congressional Delegation asking
them to sponsor legislation seeking repeal of the
law creating the Prohibition Against Billing
provision.

The board also decided to offer its assistance to
a group of Aiken physicians, led by Dr. Peggy
Fitch, who were making an effort to set up a
meeting with our Congressional Delegation in
Washington. Dr. Fitch and the Aiken physicians
met regularly to plan their presentations, and in
September Mrs. Barbara Whittaker, Dr. Dan
Brake, and I met with them to go over the final
agenda prior to the meeting in Washington on
October 3rd. We met with Senator Thurmond,
Congressman Derrick, and William L. Roper,
M.D., the Administrator of HCFA, and discussed
major problems with Medicare for one hour.

That afternoon Dr. Brake, Mrs. Whittaker and I
visited the offices of our Congressmen and talked
with them further about the problems. We subse-
quently asked our Congressional Delegation to
request a GAO study of HCFA’s implementation
of the “Unnecessary Services” provision, and we
included a draft letter from the AMA. Our Con-
gressional Delegation did request a GAO investi-
gation, which is currently being conducted.

The board later requested that Dr. Roper
change the wording on the Medicare beneficiary’s
EOMB to explain correctly the difference be-
tween the MAAC and the “allowed charge” and
to correct the inaccurate definition of “prevailing
charges.” Dr. Roper has written us back about the
changes which he has made, but the board does
not feel the changes are adequate and is continu-
ing to pursue this matter.

At the AMA Leadership Conference in Febru-

ary, the SCMA was recognized for its major role in
assisting the AMA in getting changes made in this
law and particularly for getting our Congressional
Delegation to request the GAO investigation.

Another major issue for the Board of Trustees
was the PRO Contract. Resolution F-9 at last
year’s Annual Meeting requested that the SCMA
seek to have the current PRO replaced by another
PRO more acceptable to the physicians and pa-
tients of South Carolina. The board had initially
contacted Medical Review of North Carolina in
October 1987 and asked them to consider bidding
on the South Carolina contract. After the Annual
Meeting, the board voted to support MRNC in its
bid and sent a letter to all South Carolina physi-
cians in July and requested their support for
MRNC. The Metrolina contract terminated on
September 30th, and South Carolina was left
without a PRO for several months. In December,
Medical Review of North Carolina was awarded
the PRO contract and immediately began its
work. We met with their executive director at the
January Board Meeting, and we are optimistic
that we can have a good relationship with MRNC.

The board spends considerable time discussing
pending and proposed legislation. While the Leg-
islature is in session, we track the progress of
various bills through hearings, committees, and
floor votes. Last year, no bill which we opposed
made it out of committee. For the first time in
four years, tort reform was not an issue this year.
We had agreed not to bring it back for three years
as part of an agreement at the time of the suc-
cessful passage of the S. C. Civil Justice Coalition
Bill last year.

The chiropractors, nurses, and physical thera-
pists all have bills to enhance their position. When
the chiropractors toured the state for press con-
ferences on their “Free Choice” bill (mandatory
insurance coverage), the SCMA was ready with a
prepared statement to rebut their arguments. The
nurses want to revise their “definition of nursing,”
and we are trying to reach an acceptable compro-
mise with them.

Last fall we recognized the inevitability of a bill
concerning infectious wastes. The board ap-
proved a feasibility study to review the alter-
natives for infectious waste disposal from physi-
cians’ offices. In February we sponsored a seminar
for the Legislature to inform them about the
infectious waste problem. We are working ac-
tively on the two infectious waste bills that have

April 1989

171

OFFICER REPORTS

been submitted in the Legislature, and it appears
likely that there will be a “small generator” ex-
emption for physicians’ offices. Dr. Ed Catalano
has been our major leader with regard to “infec-
tious waste” and we appreciate his efforts.

The board has met with the State Board of
Medical Examiners at the SCMA Annual Meeting
for the past few years in an effort to establish a
good working relationship. In early May an
amendment was tacked on a bill in the Legislature
that would lower the minimum score required on
one part of the FLEX Exam from 75 to 74, with an
overall average of 75 still required. This provision
was designed to allow one specific M.D. to be
licensed. The Board of Medical Examiners re-
quested that we lobby against the bill, but the bill
had enough support that its passage was assured.
Although we didn’t like the bill and the way it had
been whisked through the Legislature, we recog-
nized the medical needs of that community and
elected not to oppose the bill. The Governor al-
lowed the bill to become law without signing it
and emphasized that he did not approve of the
manner in which this change in the credentialing
process had been rushed through the Legislature.
The Executive Committee has subsequently met
with the Board of Medical Examiners to express
our concern about this change in the licensure law
and further changes that might be attempted in
the future.

After the AMA approved the Registered Care
Technologist program at the June Annual Meet-
ing, the SCMA Board received numerous letters
from nurses and a request from the South Carolina
League of Nurses that we oppose the RCT pro-
gram. The board went on record as recognizing a
deficiency in bedside patient care which the nurs-
ing profession has not corrected. The SCMA sup-
ports the development of a Nurse Recruitment
and Retention Center and other efforts to increase
the number of nurses, but feels that we must be
willing to pursue other options to correct the
shortage in bedside care providers. Since then the
SCMA officers have met with nursing groups on
several occasions to explain the RCT program and
the need to get better bedside patient care.

The board appointed an ad hoc committee,
chaired by S. Perry Davis, M.D., to review the
report of the DHEC Task Force on Hazardous
Waste. The Ad Hoc Committee submitted its
report, which was approved by the Executive
Committee, and the SCMA made a public an-

172

nouncement about it. The board will continue to
monitor this issue and appreciates the input of the
Sumter-Clarendon-Lee Medical Society.

At the 1988 Annual Meeting the House of Dele-
gates approved a resolution expressing dissatisfac-
tion with the policies of many self-insured
companies in reference to utilization review and
reimbursement mechanisms. This resolution was
further revised and taken to the AMA Interim
Meeting in December, and it passed. The AMA
Board is to “investigate current governmental
and/ or other controls over self-insured companies
to determine whether there is adequate unifor-
mity of requirements for initial and continued
hospitalization review and report to its House of
Delegates at the 1989 Interim Meeting on the
feasibility of seeking such changes which would
enhance the accountability of self-insured com-
panies in the administration of their respective
health insurance plans.”

Last June, in response to a request from the
SCMA Board and the 1987 House of Delegates,
the Chief Insurance Commissioner, John G. Rich-
ards, issued a bulletin to all health insurers regard-
ing complaints about preadmission review re-
quirements. The Department of Insurance will
not tolerate unreasonable delays and requests for
information and will maintain a file of com-
plaints. The SCMA has currently submitted a
Utilization Review Bill requiring that any physi-
cian or nurse doing preadmission or other utiliza-
tion review must be licensed in South Carolina.

The Personal Care program, a voluntary Medi-
care assignment program, has been established.
The board approved having the Commission on
Aging issue the cards to Medicare patients whose
income is at or below 150% of the poverty level. If
you are a non-participating physician and have
not signed up for the Personal Care program, I
urge you to do so. Our best chance to prevent
mandatory Medicare assignment is to demon-
strate that we are providing care for the elderly
with limited finances.

The SCMA sponsored its third annual Lead-
ership Conference in January. The program in-
cluded discussions on the SCMA legislative
agenda, Connecticut’s battle against Medicare
mandatory assignment, a report on AMA ac-
tivities in Washington, a discussion on the role of
medical ethics, and talks by the director of Medic-
aid and by the State Insurance Commissioner. The
program was excellent, and I would encourage

The Journal of the South Carolina Medical Association

OFFICER REPORTS

you to be sure that your county and specialty
society officers attend next year.

One of the duties of the board is to evaluate the
Chief Executive Officer. We have worked out a
format for annual evaluation with the CEO sub-
mitting a summary of his activities, and the board
then evaluating his performance in the seven ma-
jor areas specified by his contract. Bill Mahon
again received high marks in all categories, and
the board has reaffirmed its confidence in him.

In September, the SCMA Board held its Annual
Retreat in conjunction with the Trustees, Admin-
istrators, and Physicians Conference. The pro-
gram concentrated on the changing environment
for hospitals, governing boards, and physicians. If
your hospital does not send representatives to this
conference each year, I would encourage you to
suggest it to your hospital administrator.

The board has taken a strong position with
regard to smoking. We have voted to support the
S. C. Hospital Association policy of “No Smoking
in all South Carolina Hospitals by 1990 and have
approved a similar policy for physicians’ offices.
The board also voted to testify in support of the
Clean Air Bill before the Legislature.

The board is attempting to keep the SCMA
membership well informed about its activities.
For the past two years we have invited county
society presidents to attend the board meetings.
However, the response has been so poor that I
doubt we will continue it. This year we have been
including a summary of the board meetings in the
SCMA Newsletter, printed in The Journal. This
expanded newsletter is an excellent update on the
activities of the SCMA, Medicare, Medicaid, and
other issues that affect your practice.

I think you can see from this report that the
Board of Trustees has been very active in many
areas. I appreciate the opportunity to serve as
Chairman of the Board. I feel that we have an
excellent SCMA staff and Board of Trustees, and
they have both been very supportive. I hope that
y ou will continue to support the SCMA and will
let the board or SCMA staff know if you have
suggestions on ways that we can better serve you
or your patients.

Respectfully submitted,

J. Chris Haick, III, M.D.,
Chairman of the Board

April 1989

173

Practice
Made Perfect

GENERAL SURGERY
NEUROSURGERY

CARDIO - THORACIC SURGERY

PLASTIC SURGERY

PSYCHIATRY

ANESTHESIA

FAMILY PRACTICE

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YOU ARE THE NAVY, YOU ARE TOMORROW

APRIL 1989

NEWSLETTER

ANNUAL MEETING UPDATE

Included in this issue of The Journal are reports and resolutions
to be considered at the 141st Annual Meeting of the South
Carolina Medical Association to be held April 26 - April 30 at
the Omni Hotel in Charleston. Mailing of handbooks to delegates
is scheduled for April 10. Delegates who will be unable to
attend are urged to pass their handbooks along to their alternate
delegates since only a limited supply will be available at the
meeting. As of March 31, a total of 2 32 physicians have pre-
registered.

Susanne Geist Black, MD, nominated by the Dillon County Medical
Society, will be presented the A. H. Robins' Physician's Award
for Community Service at the Annual Meeting President's Banquet.
Congratulations to the other physicians nominated for this
prestigious award: Stoney Abercrombie, MD, Seneca; T. James
Bell, MD, Hartsville; Charles Crews, MD, Lexington; William
Lacey, MD, Pinopolis; Leslie Carl Meyer, MD, Greenville; Harry J.
Metropol, MD, Columbia; and Harold G. Morse, MD, Anderson.

ANNUAL QUALIFICATION STATEMENT REQUIRED BY PROFESSIONAL
CORPORATIONS

According to a law passed last year, all professional
corporations in South Carolina must file a qualification
statement with the appropriate licensing authority by April 1 of
each year.

Physician corporations must file such a statement with the State
Board of Medical Examiners and provide the names and usual
business addresses of their directors and officers.

If this law applies to you, please contact your attorney or the
State Board of Medical Examiners for the necessary forms to be
filed in order for you to be in compliance with the law.

HIGHLIGHTS OF MARCH 22 BOARD OF TRUSTEES MEETING

At the March 22 meeting of the SCMA Board of Trustees, several
important actions were taken.

The SC State Retirement Systems is establishing an appeals
process on insurance coverage issues for which benefits have been

denied. The special Appeals Committee on Coverage will be
composed of the Chief Insurance Commissioner or his designee; the
Director of the SC Retirement Systems or his designee; and three
physicians and/or clinical or counseling psychologists. The SCMA
and the SC Board of Psychology have been asked to submit a list
of five panelists who would be willing to serve. The SCMA is
contacting the presidents of the state's specialty societies for
nominees .

The Board heard concerns of the Small and Rural Hospital Council
regarding recruiting physicians to the rural areas. An ad hoc
committee is being organized to meet with the Hospital
Association and the State Board of Medical Examiners in an effort
to address these concerns.

The Board voted to endorse the SC Registry for Dementing
Illnesses, after hearing a presentation from Charles Still, MD,
Medical Director for the registry.

A request from the SC Pharmaceutical Association resulted in the
Board's agreement to support Bill S.378 dealing with mail order
"pharmacy". In addition, the Board voted to endorse the SC
Society of Medical Assistants, Inc., to assist them in recruiting
new members .

MEDICARE UPDATE

At recent Medicare workshops, Blue Cross and Blue Shield of South
Carolina reviewed the new HCFA policy on ICD-9-CM coding of
physician claims. Attendees at the workshop received a copy of
the AMA's New ICD-9-CM Coding Requirements pamphlet, which
summarizes these rules. To obtain a copy of this AMA brochure,
contact Kim Fox, SCMA (1-800-327-1021).

At the workshops, the following points were explained:

Physician claims must include codes from 001.0 through
V82.9.

The following rule is different from that used in hospital
coding; i.e., on physician claims diagnoses documented as
"probable" or "rule out" should not be coded as if the
diagnosis was confirmed. Instead, code to the highest
degree of certainty; codes for symptoms are acceptable.
Failure by radiologists and pathologists to list a second
code in addition to a V-code (such as V72.5 or V72.6) may
result in a request for additional information from the
carrier.

The carrier "strongly recommends" that the primary physician
record the reason for tests and x-rays when they are
ordered.

Your staff should use the Third Edition of the ICD-9-CM code
book. To order, send $43.00 to ICD-9-CM, Third Edition,
Volumes 1 & 2 , PO Box 360121, Pittsburg, PA 15250-6121.

Checks should be made out to "Superintendent of Documents."

Referring Physician Medicare Number

Medicare has clarified that the new requirement to include the
Medicare provider number of the referring physician applies only
to the following claims by physicians: independent labs,
radiology and pathology.

PRO UPDATE

Keith H. Waters, MD, has been named Medical Advisor for Carolina
Medical Review, the designated PRO for the state of South
Carolina. As medical advisor, he will be responsible for
providing the internal medical expertise needed to effectively
maintain a medical peer review program for the physicians of this
state. A native of North Augusta, SC, Dr. Waters received a BA
in English from Clemson University and later received his Doctor
of Medicine from the Medical University of South Carolina. He
has 11 years experience as a physician and flight surgeon for the
US Army, where he devoted considerable time to administrative
medicine, utilization review, quality assurance and peer review.
Prior to coming to CMR, Dr. Waters was a family physician in
Easley, SC.

JUSTICE OFFICIAL WARNS PHYSICIANS ABOUT PRICE FIXING

Physicians who agree to fix prices, allocate territories or
boycott competing health care providers will find themselves in
more than just a little hot water with the Justice Department's
active antitrust enforcement policy. Assistant Attorney General
Charles Rule, speaking before the AMA House of Delegates,
cautioned physicians that price fixing and certain other
agreements among physicians are "unlawful regardless of their
purpose or effect." "Such agreements may be criminal, even if
physicians seek to ensure care of a higher level of quality or to
safeguard the profession's ethical standards," he said.

Unlike the gray zones inherent in civil violations of the
antitrust laws. Rule said criminal violations under antitrust
laws are clear cut and can be avoided by adhering to the
following guidelines. Specifically, physicians should not enter
into agreement with competing physicians (1) on price, quantity
or quality of services, including fee schedules and relative
value scales; (2) on patients who will receive services, areas
from which patients will be drawn and locations of offices; (3)
and on refusals to offer services to alternative delivery
systems .

HEALTH CARE FACILITY INVESTMENTS

The AMA is seeking illustrative examples of health facility
investments physicians have made outside their practice for the
primary purpose of providing patients with access to quality care
in the communities where they practice.

Such documented situations are needed to respond to examples of
abusive self-referrals that have been cited by proponents of
legislation, such as Pete Stark's proposed H. R. 939, which would
impose a virtual ban on physician referrals to facilities in
which they or a member of their family have made investments.

If you can furnish such an example, please contact Barbara
Whittaker at SCMA.

THE CENTER FOR REHABILITATION TECHNOLOGY SERVICES

The Center for Rehabilitation Technology Services is a national
rehabilitation engineering center funded to address service
delivery needs for assistive technology in South Carolina and in
the southeastern United States. The center, or CRTS, is part of
the South Carolina Vocational Rehabilitation Department and is
supported by the National Institute on Disability and
Rehabilitation Research; however, CRTS can serve any disabled
person, not only vocational rehabilitation clients. For
information, please write to the Project Director, CRTS, 1410-C
Boston Avenue, PO Box 15, West Columbia, SC 29171-0015; or call
(803) 739-5362.

NOMINATIONS FOR AMA APPOINTMENTS

The AMA is soliciting recommendations for appointments to a
variety of committees, including Graduate Medical Education,
Continuing Medical Education, Residency Review and Medical
Specialty Boards. If you are interested in serving on an AMA
committee, please contact William Mahon at the SCMA prior to
April 21.

SCMA MEMBERSHIP ACHIEVEMENT

Congratulations to Hampton County Medical Society which has
achieved 100 percent membership in the SCMA!

UPCOMING CONFERENCES

The AMA is one of several co-sponsors of the International
Conference on Genetic Variation and Nutrition, June 22-23 in
Washington, DC. Registration fee is $150 before May 31; $200

after May 31. Write Artemis P. Simopoulos, MD, director, Center
for Genetics Nutrition and Health, American Association for World
Health, 2001 S. St., NW, Suite 530, Washington, DC 20009.

SCMA NEWSLETTER
is a publication of the
South Carolina Medical Association.
Contributions welcomed.
Melanie McLendon, Editor
798-6207, in Columbia

TRUSTEE REPORTS

FIRST MEDICAL DISTRICT

It has been an honor and a pleasure for me to
serve as your representative to the Board of Trust-
ees from the First District. This has been my first
year as a trustee, and I have found it to be reward-
ing and exciting to be involved in the future and
policymaking decision of the SCMA and for medi-
cine in South Carolina. I have attended all of the
board meetings and also attended the TAPS Con-
ference at Hilton Head Island this year. I have also
served as a trustee on the board of the South
Carolina Institute of Medical Education and Re-
search as well as a board director for the South
Carolina Political Action Committee.

The most enjoyable activity has been going out
to the different component medical societies and
visiting with them. At the present time, the most
rewarding activity is working with the Beaufort
and Hilton Head Medical Society. They are now
an active medical society and are having meetings
with most interesting speakers. It is still debatable
as to whether they will remain as one medical
society or will separate into two medical societies.
The geography of the area necessitates the pos-
sibility of splitting into two component medical
societies due to the distance of approximately a 45
minute drive from one area to the other.

It has been my privilege representing my col-
leagues from the First District over the past year
at the SCMA Board of Trustees. I have endeav-
ored to perform this task in an acceptable fashion
and look forward to serving you in the future.

Respectfully submitted,

John B. Johnston, M.D., Trustee

FIRST MEDICAL DISTRICT
(METROPOLITAN)

I am completing my fourth year as a member of
the Board of Trustees and first year as Chairman
of the Board. The SCMA Board continues to be
very active in all areas that impact on South
Carolina physicians and their patients, and I think
it’s safe to say that we will have major issues,
including some unexpected ones, to deal with
each year.

For some problems, such as the Medicare PAB
Notices, we will need to work through the AM A,
HCFA. and Congress because the issue affects all
states and is decided at a national level. But
“state’ problems are decided by state employees
or the Legislature, and the results depend entirely
on our efforts. Bill Mahon and the SCMA staff are
doing an excellent job in presenting our position,
but we physicians must be willing to contact our
legislators and do our part if we are to be suc-
cessful. One problem with having an excellent
staff is the natural tendency to let them do all the
work. We all need to establish a working rela-
tionship with our legislators so that we can let
them know our opinion on significant legislation.
If you have not been the Doctor of the Day, I
encourage you to do so. It is a good opportunity to
view the work of the Legislature, and I have been
assured that no other Doctors of the Day will be
forced off the Senate floor!

This year I attended the AM A Annual and
Interim Meetings, as well as the AMA Leadership
Conference. I was impressed at all three meetings
with the tremendous dedication and commitment
of the Delegates and State Officers. At the AMA
Leadership Conference, the SCMA was singled
out for its efforts regarding the Prohibition
Against Billing Notices and for getting the S. C.
Congressional Delegation to request a GAO audit
on the HCFA and Medicare carrier implementa-
tion of this law.

The Resource Based Relative Value Scale was
the major topic at the AMA Meeting in December.
I was impressed with the willingness of the dele-
gates to put aside their differences and act with
unity in the best interest of the profession. I hope
that we can convince all of our colleagues at home
to do likewise. As a surgeon, I am in the group
which stands to lose from any significant overhaul
of the current reimbursement system, but I fear
we will lose much more if we don’t stand united
on this issue.

I have addressed specific issues in the Chairman
of the Board s Report, and I hope that you will
review it.

We have a strong Board of Trustees and a
dedicated staff at SCMA, and we need your active
participation in the many activities in our organi-

April 1989

179

TRUSTEE

zation. I hope that you will consider ways to
improve the SCMA and let your ideas be known to
the staff or members of the board.

Respectfully submitted,

J. Chris Hawk, III, M.D., Trustee

SECOND MEDICAL DISTRICT

It has been an honor for me to have served as
your Second District Trustee for the past three
years, and I thank you for allowing me this
privilege.

In addition to attending the regular board
meetings and the Board Retreat, I have acted as
the board liaison to the Legislative Committee.
This committee, ably chaired by Dr. Jim Pruitt,
makes recommendations of support or opposition
to various bills introduced into the State Legisla-
ture. These recommendations are then passed on
to the board for its approval or rejection.

I have also served as vice chairman of SOCPAC
for this past year. SOCPAC has made tremendous
strides in the past several years, and this year we
have over 1,000 members.

The Candidate Review Committee of SOCPAC
is a very interesting and important committee on
which I continue to serve. This committee decides
which candidates to support and how much finan-
cial and other aid we will give. This is a non-
partisan committee with the primary goal of im-
proving the practice of medicine in the state. We
also make recommendations to AMPAC for sup-
port or opposition in federal campaigns.

This year has been a good year for the SCMA.
We have worked for and obtained significant
improvement in tort reform. We have also been
very influential in finally ridding ourselves of an
unfair and arrogant PRO, but we still have to face
the issues of mandated assignments and problems
with DRG’s plus chiropractic bills.

We need all the help we can muster. Please get
politically involved and help those in the Legisla-
ture that are helping us. Join SOCPAC and ask
your colleagues to join us in making SCMA even
stronger.

Respectfully submitted,

Frank W. Young, M.D., Trustee

REPORTS

SECOND MEDICAL DISTRICT
(METROPOLITAN)

This past year I have faithfully attended the
South Carolina Medical Association Board of
Trustees Meetings, the Executive Committee
meetings, the Committee to Plan State Meetings
and a number of other associated meetings and
functions.

Physicians who disdain involvement in orga-
nized medicine and participation in the political
process profess a desire to concentrate on the
practice of their profession. They feel that by
practicing quality medicine, the majority of the
problems assaulting us will resolve themselves.
This approach demonstrates a lack of understand-
ing of ‘The American Way. ” This past year I have
been amazed to learn of the tremendous amount
of legislative initiatives which have the potential
to significantly alter the manner and the extent of
our medical practices.

The SCMA has worked tirelessly and effec-
tively to promote the best interest of our patients
and to maintain the integrity of our profession. In
their own fashion, the combined efforts of the
SCMA are as important as the activities of the
State Board of Medical Examiners in preserving
our ability to insure quality medical care within
South Carolina. This past year my major contribu-
tion in these efforts has been in working with the
infectious waste legislation. I am confident that
we can end up with a reasonable bill which pro-
tects the public health and the environment with-
out penalizing health care providers within the
state.

I view the current leadership of the South Caro-
lina Medical Association as truly representing the
best interests of the physicians of the state as well
as their patients. I appreciate being given the
opportunity to participate and help guide this
organization in a direction which will make it
even more valuable and responsive in the future.

Respectfully submitted,

Edward W. Catalano, M.D., Trustee

THIRD MEDICAL DISTRICT

This has been a rather interesting year thus far.
As Trustee of the Third District, I attended meet-
ings of the board up to the time of this report. We

180

The Journal of the South Carolina Medical Association

TRUSTEE REPORTS

have accomplished a lot this past year, and during
this current year we will continue to work on
problems that concern our membership. The Per-
sonal Care program is in progress and material has
already been sent to those members planning to
participate. The liability insurance problems are
also being monitored.

Much information was obtained at a joint meet-
ing with the Hospital Governing Board members
at the Fall Retreat at Hilton Head. This meeting
concerned the policies from the Health Care Fi-
nancing Administration in Washington.

It was a privilege to have our President,
Tommy Rowland, and our Executive Vice Presi-
dent, Mr. Bill Mahon, meet with the Greenwood
Medical Society in January. Tommy gave a very
comprehensive speech to the members. He will
meet with the Laurens County Society in March
at which time I will be out of town and regrettably
unable to attend this meeting.

Currently, we are looking forward to the SCM A
Annual Meeting which will be held in April at the
OMNI Hotel in Charleston.

I would like to thank the members from the
Third District for their cooperation and stand
ready and willing to assist any member of our
society in any way possible. I appreciate very
much your allowing me to serve these past four
years and look forward to further service.

Respectfully submitted,

Richard M. Carter, M.D., Trustee

FOURTH MEDICAL DISTRICT

The officers and administrative staff of the
South Carolina Medical Association, supported by
the Board of Trustees, and the faithful work of
many active committees, have accomplished
much for all physicians of South Carolina in the
last year.

Our Ethics Committee presented “Principles of
Medical Ethics of the South Carolina Medical
Association.” A “Personal Care” program for the
low income Medicare patients is in place and
working. A health education van, fostered mainly
by our auxiliary, is ready for use in the schools of
our state.

The scientific program at the Annual Meeting
has progressively become a high quality benefit
for physicians in our state.

Through the work of the Committee on Profes-
sional Liability and the Risk Management pro-
gram, plus the efforts of many to effect tort
reform, the malpractice climate in South Carolina
is among the best in the country.

The JUA and PCF have performed so well that
there will not be a premium increase this year.

The Legislative Committee has been very ac-
tive and effective.

The Doctor of the Day program has continued
under our sponsorship and has been very ef-
fective.

SOCPAC is growing and is very effective.

The Members’ Insurance Trust offers excellent
coverage for our members and their families and
is now processing all claims in-house rather than
contracting this function.

The Committee on Physician Advocacy and
Assistance has been active and responsive to the
needs of a number of physicians.

The Occupational Health Committee con-
tinues to maintain good rapport with the South
Carolina Workers Compensation Commission ef-
fecting updating of the fee schedule and review-
ing problems.

Many other committees have worked hard and
long to maintain the excellent record of service of
the medical association.

Personally, your trustee has participated in
meetings of the Board of Trustees, served on the
Legislative and Mediation Committees, partici-
pated in the Doctor of the Day program, attended
the Leadership Conference and contacted a
number of legislators at times throughout the
year.

As President of the Medical Care Foundation, I
am serving on the Board of the Medical Review of
North Carolina, our new South Carolina PRO.

The death of several members in our district has
been noted and appropriate letters from the South
Carolina Medical Association were written to
families of these deceased members.

It is an honor and privilege to serve as Trustee of
the Fourth District.

Respectfully submitted,

William J. Goudelock, M.D., Trustee

April 1989

181

TRUSTEE REPORTS

FOURTH MEDICAL DISTRICT
(METROPOLITAN)

The 1988-1989 year has gone well for the
SCMA. Memberships both in the general member
classification as well as SOCPAC have increased.
The SCMA s efforts to monitor health legislation
and to work to improve the health of South Caro-
lina citizens has continued. In my opinion, our
administrative staff is working well to accomplish
these goals. In particular, efforts have been made
for quick responses by the SCMA to pertinent
media reports. Also, SCMA has established a
working relationship with our new PRO.

The SCMA subsidiaries continue to function
well in providing continuing medical education
and insurance benefits through the SCMA Mem-
bers’ Insurance Trust and SCIMER.

Particular areas of recent importance have
been our successful efforts to modify our tort
system and to help advise our citizens on issues
concerning toxic and infectious waste. The suc-
cessful “Personal Care’’ program has received a
great deal of positive publicity and provides a
needed service for the citizens of our state who
have an annual income below 150 percent of
poverty.

Personally, it has been my pleasure to serve on
the SCMA Health Education Van Committee.
Under the guidance of Betsy Terry and Madge
Littlejohn, this endeavor has been successfully
completed and should be available to the citizens
of our state at the time of our Annual Meeting.

Respectfully submitted,

James B. Page, M.D., Trustee

FIFTH MEDICAL DISTRICT

The past year has again been a busy one both
for me and for the SCMA. Unfortunately, my
personal schedule has conflicted with the SCMA
schedule several times, and I have not been able to
attend all the board meetings. Likewise, although
I was able to attend a portion of the Board Retreat
at Hilton Head, my schedule forced me to miss
part of it.

I have been able to attend several meetings of
the Lancaster County and Fairfield County Medi-
cal Societies as well as those in York County. The
York County Medical Society was fortunate to

182

have our current president, Dr. Thomas Rowland,
Jr., as well as our Executive Vice President, Bill
Mahon, address a monthly meeting.

The efforts of the board as well as SCMA mem-
bership in effecting changes in the PRO have
been noteworthy. I believe it shows how effective
organized medicine can be when a united front is
presented.

This is the second year of my second two-year
term on the Board of Trustees. As mentioned in
the first paragraph, my schedule this year has not
allowed me to participate as actively as I would
prefer. Since next year looks to be a repeat, I feel it
in the best interest of the SCMA to have a differ-
ent trustee from the Fifth Medical District next
year. I do, however, want to thank the members of
this district for allowing me to serve as their
representative during the past four years and
pledge my support to the new trustee chosen.

Respectfully submitted,

Terry Dodge, M.D., Trustee

SIXTH MEDICAL DISTRICT

This is my first year on the Board of Trustees of
the South Carolina Medical Association. I have
been very impressed by the quality of the work
that the board performs. I believe we are all being
well-served by our leadership and staff.

I have been able to visit my component medical
societies and have noted there have been many
questions concerning Medicare/PRO/Medicaid
issues and a reasonable amount of discussion about
the AMA’s RCT proposal.

I have sent the county medical society presi-
dents and SCMA House of Delegates from each
county brief written summaries of the Board of
Trustee meetings and these reports seem to have
been well-received.

I have enjoyed serving and wish to thank the
delegates for their support.

Respectfully submitted,

Stephen A. Imbeau, M.D., Trustee

EIGHTH MEDICAL DISTRICT

At the 1988 South Carolina Medical Association
meeting in Charleston, my colleagues from the

The Journal of the South Carolina Medical Association

TRUSTEE REPORTS

Eighth Medical District did me the honor of re-
electing me to a third term as their representative
on the SCMA Board of Trustees.

In that position, I have attended all board meet-
ings except the Retreat at Hilton Head. Schedul-
ing difficulties prevented my attendance there. I
have also attended meetings of the Maternal, In-
fant and Child Health Committee of the SCMA as
their liaison member.

In addition to the above, I, as president of the
S. C. Chapter of the American Academy of Pedi-
atrics, have attended all of their meetings. In my
Annual Report last year, I stated that I thought
that two of the most important issues facing our
organization in the coming year would be at-
tempting to have Metrolina replaced and passage
of a vaccine injury bill. I am happy to say that
Metrolina has been replaced by Medical Review
of North Carolina and that the SCMA will submit
a vaccine injury bill for consideration by the Leg-
islature when the AAP approves one of the two
bills now pending. Most of you are aware of the
other measures of Tort Reform that the leaders of
the SCMA were able to bring about. Those of you
who were not familiar with the Charitable Immu-
nity Act should investigate its provisions. It would
be time well spent. In the Eighth District, all
county leaders have been contacted, delegates
and alternate delegates’ names secured and sub-
mitted, and visits by the president of the SCMA to
local societies scheduled.

As a member of the Board of the SCMA Mem-

bers’ Insurance Trust, I am proud to have been a
part of the expansion in membership of that orga-
nization and also of the expansion of benefits to its
members. I have attended all meetings of the MIT
Board.

It has been my pleasure as the representative
holding your seat on the SCMA Board of Trustees
to furnish several newsletters to the leaders of the
various county medical societies regarding the
problems faced by the board and the actions taken
by the board.

Many new problems will face the board in the
coming year, including effecting a smooth transi-
tion to Medical Review of North Carolina, push-
ing a vaccine injury bill through the Legislature (it
is to their benefit as well as ours that a bill be
passed because of the enormous cost to the state
for vaccine otherwise), and the constant guarding
against encroachment by third, and sometimes
fourth parties, in the practice of medicine.

In April I will begin my final year on the board
(I am not eligible for reelection in 1990), and I
wish to thank my colleagues from the Eighth
District for the honor of serving the maximum
time allowed by our by-laws. You are well-repre-
sented by the SCMA and board officers who spend
untold hours in representing you in matters of
medicine. I pledge my continued best in repre-
senting the Eighth District during the next year.

Respectfully submitted,

John W. Rheney, Jr., M.D., Trustee

April 1989

183

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COMMITTEE REPORTS

ADVISORY COMMITTEE TO THE
SOUTH CAROLINA DEPARTMENT
OF VOCATIONAL
REHABILITATION

The South Carolina Medical Association Ad-
visory Committee to the South Carolina Depart-
ment of Vocational Rehabilitation met on Febru-
ary 21, 1989, at the Sheraton Northwest in Colum-
bia. Dr. Ben N. Miller, Chairman, presided. Mem-
bers of the committee present were: Dr. Alec
Brown, Columbia; Dr. Edward E. Kimbrough,
Columbia; Dr. Woodrow W. Long, Jr., Green-
ville; Dr. James E. Padgett, Jr., Columbia, repre-
senting DHEC; Dr. James F. White, Columbia
and Ms. Barbara Whittaker, Columbia, represent-
ing the South Carolina Medical Association.

Vocational Rehabilitation was represented by
Mr. Joe S. Dusenbury, Commissioner; Mr. Preston
Coleman, Assistant Commissioner — Administra-
tive Services; Mr. Walter J. House, Client Services
Consultant; Dr. Paul G. Knight, Assistant to the
Commissioner for Client and Psychological Ser-
vices; Mr. Anthony S. Langton, Jr., Project Direc-
tor; Mr. Charles LaRosa, Assistant to the Commis-
sioner; Mr. David C. Lever, Supervisor Compre-
hensive Programs; Mr. Gregory W. McGrew, En-
gineering Associate; Mr. Edward H. McMillion,
Director, Staff Development and Training; Mr.
Wayne Nance, Quality Assurance Analyst, Dis-
ability Determination Division; Mr. Richard A.
Vandiver, Director, Disability Determination Di-
vision; and Dr. James H. Weston, Physician, Dis-
ability Determination Division.

Dr. Ben N. Miller welcomed the members of
the Advisory Committee and stated that it was a
sacrifice for everyone to get together, but it is
essential for rehabilitation and the liaison for the
medical and dental profession to the agency. He
asked that the members enter into the discussion
during the meeting.

Mr. Anthony S. Langton, Jr., Project Director,
was presented and he stated that at present there is
a five-year grant project that is designed to look
into the delivery of technology related systems
versus disability in the state of South Carolina.
This program is involved with all agencies for
early intervention programs from ages one or two
to older adults. Technology and technology re-

186

lated devices information is made available to
those who have disabilities. This is being coordi-
nated through Vocational Rehabilitation and vari-
ous school systems. The staff is involved in looking
at how technical assistance can be provided to key
agencies. The grant provides for the setting up
and giving information on assistive aids and de-
vices and how to utilize research reports. He
stated that a newsletter would be put out in ap-
proximately two weeks with information related
to the assistive devices. There have been two
training workshops: one dealt with adaptive driv-
ing and vehicle modifications for spinal cord inju-
ries and the other with how to accommodate
severely disabled persons in the work-site. The
staff will work with school systems, facilities and
hospitals in providing technology resources to dis-
abled persons. The grant has been in operation for
approximately one year and at this point the staff
is ready to respond to information requests by-
providing technical assistance. At present, we are
working with the Medical University of South
Carolina, University of South Carolina and Clem-
son University. This program is not restricted to
working with Vocational Rehabilitation clients
but will reach out to the disabled of the state.

Mr. Gregory W. McGrew, Engineering Associ-
ate, was introduced and he stated that he is with
the Department of Vocational Rehabilitation and
as such works strictly with the Vocational Re-
habilitation clients. He acts as a rehabilitation
technology problem solver for Vocational Re-
habilitation clients. Over the past one and half
years, the program has been involved in job ac-
commodations which will enhance the employ-
ment of clients in specific jobs. An example is a
client with a back injury who works in a sewing
factory is only able to work part-time because she
is unable to tolerate the pain brought on by the
injury. A simple type of seating adaptation and
adjustment of the chair or adjustment of the
height of the pedal on the sewing machine can be
made to accommodate the client enabling her to
continue in employment. Sometimes the problem

The Journal of the South Carolina Medical Association

COMMITTEE REPORTS

solving involves evaluation of the problem and
identifying the available type of devices to ad-
dress the problem. The goal, when Vocational
Rehabilitation works with clients, is to make the
clients competitive.

Mr. McGrew is also involved in home ac-
cessibility. Clients often need information regard-
ing what can be done to their home to allow them
access to the bathroom, etc. Upon request, Mr.
McGrew will go into the home and do a home
accessibility evaluation and give this information
to the vocational rehabilitation counselor so that
he may discuss this with the client and make
whatever modification possible. Health mainte-
nance is also an area in which the rehabilitation
engineer is involved. This includes adaptive de-
vices for clients with problems with upper and
lower extremities where lateral pads would be of
benefit.

Mr. Richard A. Vandiver, Director, Disability
Determination Division, was introduced and
stated he had five areas he wanted to mention as
follows: 1) The courts have been involved with
issues of physical examination obtained in connec-
tion with the disability process. The courts feel
that the treating physicians are to be the primary
source for those examinations. The division is in
agreement with this decision due to the fact that
the treating physician provides the best source of
information since he or she has the historical
background in which to relate current findings. 2)
The courts have also insisted that the disability
program ask for the findings of the treating physi-
cians in the context of work-related activities. The
physician must relate to the functional limitations
that the impairment causes in order for the divi-
sion to apply it to the disability law. 3) Pain is an
issue that Congress has insisted that SSA and the
Disability program, throughout the country, in-
corporate more into the disability decision. There
are procedures that allow more historical infor-
mation about the way the claimant’s pain may
affect his daily activity or his ability to work. With
this information the division has been able to
actually bring in pain as an issue in making a
disability decision more so than in the past. The
medical profession was encouraged to continue to
provide evidence about how pain affects the
claimant in his ability to walk or engage in daily
activity. 4) The fee schedule is another area in
which the department is sensitive and is trying to
be competitive with other programs in the state

and region. It was pointed out that there have
been some substantial cuts in the amount of
money available to purchase medical evidence,
examinations and historical evidence, etc. It was
asked that the medical profession bear with the
department during the lean times because every-
thing possible is being done to stay within a rea-
sonable financial situation. The fees in certain
areas are being reviewed and changes are being
made where possible. 5) There is a mandate from
Social Security to regional offices that a continu-
ing medical education program be implemented.
This program will be for treating physicians.

Mr. Vandiver thanked the medical profession
in the state and stated that without their help they
could not have been as successful.

Mr. Joe S. Dusenbury, Commissioner, stated
that this has been an exciting year for Vocational
Rehabilitation and that he expects the future to be
just as exciting.

At this point the meeting adjourned for dinner
and continued comments and questions. There
being no further discussion or business, the meet-
ing was adjourned.

Respectfully submitted,

Ben N. Miller, M.D., Chairman

AGING AND MEDICARE

The SCMA has been active in Medicare issues
this past year. Representatives of the SCMA Board
of Trustees visited our Congressional delegation in
Washington to discuss problems with existing
Medicare laws, including mandatory assignment
for lab work, medically unnecessary letters, and
MAAC’s. Discussions were also held with William
Roper, MD, of HCFA, regarding HCFA’s imple-
mentation of these requirements, Explanation of
Medical Benefits (EOMB) wording, and HCFA/
carrier/physician relationships.

The SCMA’s Personal Care program was modi-
fied this year to include financial guidelines of
150% of poverty and the participation of the
county aging providers. Much positive press was
attained as a result of this program.

SCMA staff continues to assist our members and
their office staffs with Medicare problems and
questions. Each month’s newsletter in The Jour-
nal of the South Carolina Medical Association
has included important Medicare information.

April 1989

187

COMMITTEE REPORTS

The SCMA’s CME Committee has included in
this year’s Annual Meeting a workshop on “The
Geriatric Patient” which will address the topics of
"Management of Pressure Sores in the Nursing
Home Environment,” and "Rheumatic Diseases
in the Geriatric Population,” as well as a presenta-
tion on RBRVS.

Because the SCMA Board and staff have done
such an excellent job in addressing Medicare is-
sues, our committee met following the SCMA
Leadership meeting in order to identify the most
effective role for us. Various possibilities were
discussed and it was concluded that SCMA Board
advice was needed.

At this time, we will await board direction with
the assurance that our committee stands ready to
assist the SCMA in Medicare and aging issues.

Respectfully submitted,

William R. Griffin, M.D., Chairman

CONTINUING MEDICAL
EDUCATION COMMITTEE

Since the last report of this committee to the
SCMA House of Delegates, we have fulfilled a
goal towards which we have been striving for the
last two years. I am pleased to report that follow-
ing a site visit by two members of the Committee
on Review and Recognition of the Accreditation
Council for Continuing Medical Education, the
SCMA has received full accreditation for a three-
year period as the accrediting agency for intra-
state sponsors of CME in South Carolina.

The SCMA was commended for the CME Ac-
creditation Manual which was developed over the
past two years, and for the quality of our ac-
creditation forms and related documents.

In the latter part of 1987 and during 1988, our
committee completed site visits of those institu-
tions and organizations whose overall programs
had previously been accredited by the SCMA. All
were reaccredited. In addition, the committee
issued provisional accreditation to two new CME
programs, one at St. Francis Hospital in Green-
ville and one at Roper Hospital in Charleston.
These recent provisional accreditations brought
the total accredited by the SCMA to seven hospi-
tals and one medical society.

What this committee has accomplished over
the past two years is a direct result of the hard

188

work and dedication of committee members who
attended meetings regularly, participated in an
accreditation workshop and travelled throughout
the state on site visits. It is also a tribute to the
SCMA leadership and Board of Trustees for their
support and faith in our efforts.

The committee has been busy in other areas, as
evidenced by the scientific sessions planned for
this year’s Annual Meeting. We feel we have
again put together an outstanding schedule of
learning opportunities and hope that each of you
takes advantage of as many hours of attendance as
your schedule will permit. We have a record
number of specialty societies participating with
scientific sessions this year — a total of eight, and
the American Diabetes Association, S. C. Affili-
ate, as well.

I would like to take this opportunity to thank
the members of the committee for their hard work
and the members of the SCMA for their continued
support.

Respectfully submitted,

O'Neill Barrett, Jr., M.D., Chairman

LEGISLATIVE ACTIVITIES
COMMITTEE

Mr. Speaker, members of the House of Dele-
gates, SCMA members and guests, it is my priv-
ilege to report to you on the activity of the
Legislative Activities Committee this past year.

The committee’s primary function is to review
proposed legislation and recommend a position to
the Board of Trustees of the Association. Prior to
the opening of the current legislative session, the
committee met and considered legislation to be
introduced by the SCMA as well as issues expected
to be introduced by others.

The committee, in response to previous House
of Delegates actions, recommended that legisla-
tion be introduced (1) to require DHEC to regu-
late tanning facilities; (2) to require insurers to
give notice of any limitations or access to physi-
cians or hospitals in health insurance policies; (3)
to limit liability for bad results from vaccines
required by law to be administered; (4) to require
preadmission review to be done by a South Caro-
lina licensed physician or nurse; (5) and to provide
for a privilege to protect confidences between
patients and physicians.

The Journal of the South Carolina Medical Association

COMMITTEE REPORTS

The committee discussed various legislative
efforts expected by others. The committee recom-
mended opposing bills, if introduced, in the fol-
lowing areas: (1) mandatory insurance benefits for
chiropractors; (2) limits on physician dispensing
of drugs; (3) optometric use of therapeutic drugs;
(4) mandatory assignment of Medicare claims; (5)
mandatory generic drug substitution; and (6)
changes in the nurse practice act which would
adversely affect the licensing of nurses.

The committee discussed the issue of infectious
waste treatment and decided that the only area
that needs to be addressed is the adoption of a
precise definition. Additionally, the committee
discussed the need for protection of data collected
under the Medically Indigent Assistance Act and
in conjunction with infant mortality review pro-
grams within DHEC.

The SCMA Doctor of the Day program con-
tinues to be a valuable service to the Legislature
and to SCMA. The committee is grateful to those
of you who donate your time to serve.

On behalf of the committee members and my-
self, I would like to thank you for the opportunity
to serve on this very important committee.

Respectfully submitted,

James R. Pruitt, M.D., Chairman

MATERNAL, INFANT AND CHILD
HEALTH COMMITTEE

Our committee adopted a new name this year,
having formerly been called SCMA Perinatal and
Maternal Health Committee, in order to better
serve the children of our state. Because there was
no SCMA committee to address issues pertaining
to children, we agreed to expand our committee
responsibilities to include child health issues.

This was also the first year for us to serve as
chairmen of this committee and we are both
grateful to the former co-chairmen, Tom Austin,
M.D., and Hal Rubel, M.D., for their assistance.
Patricia Healy and Barbara Whittaker of the
SCMA staff have also greatly helped us fulfill our
duties.

We are proud of our accomplishments this year
which include:

• a special issue of The Journal of the South
Carolina Medical Association which was de-
voted to Adolescent Pregnancy in South Car-

olina. (July, 1988: Guest Editors — Sam Elhas-
sani, M.D.; Thomas Hepfer, M.D.; and Hal
Rubel, M.D.);

• input into DHEC s proposed fetal mortality
review;

• input into DHEC’s proposed regulations for
Level I, II, and III OB and nursery services;

• preparation, distribution, and analysis of a
joint SCMA/DHEC survey mailed to all S. C.
physicians who provide obstetric care regard-
ing problems with access to prenatal care;

• discussions with the State Health and Human
Services Finance Commission regarding OB
and pediatric reimbursement with increases
in reimbursement and pediatric minicode
book prepared as a result of these discussions;
and

• support of DHEC testing of Hepatitis B for
prenatal patients and newborns.

The obstetricians of the committee were asked
to meet with representatives of the South Carolina
Hospital Association, staff of the Joint Legislative
Health Planning and Oversight Committee, and
staff of the Division of Research and Statistical
Services Division of the Budget and Control Board
in order to discuss rates of Caesarean sections.

Other members of the committee served on a
special task force created by Mike Jarrett, Com-
missioner of DHEC, to study the prenatal access
problems in the state. Some members served on
the Governor’s Maternal, Infant, and Child
Health Committee.

We continued to review maternal mortalities
and continued to serve as a forum for coordination
of medical concerns relating to maternal and per-
inatal health and now children’s health in the
state.

Respectfully submitted,

Alexander R. Smythe, II, M.D.,
Co-Chairman
R. C. Pendarvis, Jr., M.D.,
Co-Chairman

MEDIATION COMMITTEE

The Mediation Committee of the SCMA met in
March to review the pending complaints filed
with the committee.

Twenty-two complaints came to the Mediation
Committee from April 1988 to April 1989. Of this

April 1989

189

COMMITTEE REPORTS

number, six were non-members of the SCMA; (the
committee has no jurisdiction in these cases, but
urged the physicians to join SCMA); six are pend-
ing at the local level; one was withdrawn; and nine
were resolved at the local Grievance Committee
meeting.

The committee compliments the very efficient
and active Grievance Committees of the compo-
nent medical societies, who are capably handling
complaints that come under their jurisdiction.

I wish to thank the committee members and the
SCMA staff for their support this past year.

Respectfully submitted,

Albert G. LeRoy, Jr., M.D., Chairman

MEDICAL ETHICS COMMITTEE

I would first like to express my appreciation to
the House of Delegates for your support of our
committee’s efforts as demonstrated by your
adoption last year of the “Principles of Medical
Ethics of the South Carolina Medical Association”
and the ethical statements on “AIDS and Sero-
positive Patients and Physicians.” At this year’s
Annual Meeting, the Medical Ethics Committee
and SCIMER have arranged for Nancy Dickey,
M.D., to be the Leonard Douglas Memorial
speaker and a workshop leader.

The committee has remained quite active. We
have invited a panel of non-physician medical
ethicists to serve as consultants to our committee,
and we are thankful for their input. These consul-
tants are: Nora Bell, Ph.D., Albert Keller, Ph.D.,
Stuart Sprague, Ph.D., and Douglas McDonald,
Ph.D. With the assistance of our consultants, the
committee presented a lunchtime discussion on
“The Role of Medical Ethics in Our Identity” at
the SCMA’s January 1989 Leadership Con-
ference. We are also planning a discussion for the
September Trustees, Administrators, and Physi-
cians’ Meeting which is cosponsored by the South
Carolina Hospital Association, South Carolina
Medical Association, and South Carolina Associa-
tion of Hospital Governing Boards.

Our ongoing endeavors include: preparation of
an article for submission to The Journal of the
South Carolina Medical Association on the
SCMA’s Principles of Medical Ethics; physician
dispensing; the ethical issues pertinent to a physi-
cian as a witness in various legal proceedings;

190

justice and indigent care; and a Journal update on
living wills now that the S. C. law has been
amended.

Presently, we are reviewing the recent opinions
from the AMA’s Council on Ethical and Judicial
Affairs regarding: post operative care, age-based
rationing of care, anencephalic infants as organ
donors, advertising and publicity, gene therapy
and surrogate mothers.

Although we have a busy agenda, we welcome
suggestions from the SCMA membership as to
other areas for the committee’s study.

Respectfully submitted,

Donald Saunders, M.D., Chairman

MEMORIAL COMMITTEE

This year it is just and proper that our medical
association stop its business at this time and pay
honor and tribute to our fellow physicians who
have deceased since we last met. They belonged to
the great fraternity of practitioners of medicine —
the greatest fraternity in the world. These men
and women performed their art, lived with honor
and respect, served others in many ways within
their communities. Success has been defined as
follows: “He has achieved success who has lived
well, laughed often, and loved much; who has
gained the respect of intelligent men, and the love
of little children, filled his niche, accomplished his
task and left the world a better place in which to
live.” I submit to you that these were successful
men and women. After I have read their names,
we will stand for a moment of silence: Warren S.
Smith, M.D., Walterboro; Roland W. Penick,
M.D., Greenville; Stanley I. Coleman, Sr., M.D.,
Greer; John T. Davis, Sr., M.D., Walhalla; Wil-
liam H. Johnson, M.D., Loris; Thomas Rucker
Gaines, M.D., Anderson; Paul Watson, Jr., M.D.,
Columbia; Edgar Eugene Jones, II, M.D., Mt.
Pleasant; Thomas Michael Essman, M.D., Simp-
sonville; Ralph P. Baker, M.D., Newberry; Joseph
I. Hoffman, M.D., Charleston; William W. Vallot-
ton, M.D., Charleston; Hilla Sheriff, M.D., Co-
lumbia; Robert M. Dacus, Jr., M.D., Greenville; J.
Douglas Balentine, M.D., Charleston; Robert W.
Leonard, M.D., Spartanburg; Charles R. Griffin,
M.D., Pendleton; Joseph L. Goodman, M.D., Mt.
Pleasant; D. Lesesne Smith, M.D., Spartanburg;
Ira Barth, M.D., Marion; Norris James Knoy,

The Journal of the South Carolina Medical Association

COMMITTEE REPORTS

M.D., Bamberg; Abraham Max Robinson, M.D.,
Columbia; Leroy Beattie Dennis, Jr., M.D.,
Bishopville; and William Hayne Folk, M.D., Spar-
tanburg; William Amspacher, M.D., Greenville;
Henry Russell Ennis, M.D., Camden; James Ra-
venel Cain, M.D., Columbia; Oliver M. Kirkland,
M.D., Spartanburg; Benton M. Montgomery,
M.D., Newberry; and W. W. King, Sr., M.D.,
Batesburg.

Respectfully submitted,

R. Rion Dixon, M.D., Chairman

MENTAL HEALTH COMMITTEE

Mr. Speaker, members of the House of Dele-
gates, SCMA members and guests, it is my priv-
ilege to report to you on the activity of the Mental
Health Committee this past year.

The Mental Health Committee met on Sep-
tember 28, 1988. The committee recommended
support of legislation establishing privileged com-
munications between patients and physicians in
the treatment of mental and emotional conditions.
The committee reviewed proposed legislation re-
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children; mental health patient’s rights; and trans-
portation of mental health patients. The commit-
tee discussed the need for more nursing home
beds to relieve the problem of inappropriate ad-
missions to Crafts-Farrow and to insure availabil-
ity of beds there when needed.

In addition to legislative activities, the commit-
tee renewed its request to SCMA to sponsor semi-
nars on treating trauma victims and encouraged
SCMA to collect data on the amount of charitable
care given by physicians in the categories of (1)
direct care and (2) community service.

Physicians on the committee have been respon-
sive to changes in the approach to mental health
care and have been willing to testify before legis-
lative committees in response to bills affecting
that care.

Respectfully submitted,

Richard K. Harding, M.D., Chairman

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April 1989

191

COMMITTEE REPORTS

OCCUPATIONAL MEDICINE
COMMITTEE

The SCMA Committee on Occupational Medi-
cine held quarterly meetings during 1988. The
Schedule of Fees for Physicians and Surgeons for
Services Rendered under the South Carolina
Workers’ Compensation Law was not revised and
reprinted during the year, but many deletions and
additions were evaluated to conform with
changes in the 1988 CPT Manual. Many hours
were contributed to this effort by all members of
the committee.

Physicians’ fees which seemed inappropriate to
the Medical Department of the Industrial Com-
mission were reviewed at each meeting, and rec-
ommendations were made to the commission on
an individual case basis.

The committee hosted a dinner meeting with
the commission during the year. As usual, this
meeting prompted very frank and very produc-
tive discussions of our mutual problems and con-
cerns relating to providing the best possible
medical care for South Carolina’s injured workers
at the lowest possible cost.

Members of the committee participated in the
planning and presentation of two educational
seminars sponsored by the commission during the
year. Both seminars were well attended and very
worthwhile.

The committee has been hard at work over the
past two years trying to get the South Carolina
Workers’ Compensation Commission to increase
fees paid to physicians who treat injured workers.
The last fee increase was three years ago. The
SCMA Board of Trustees commissioned Ernst and
Whinney to study the fee problem and make
recommendations to the SCWCC and the com-
mittee. The committee is happy to report that the
SCWCC has approved a compromised increase in
the Fee Schedule which will go into effect April 1,
1989.

In summary, 1988 was another busy year for
the committee in fulfilling its role as liaison be-
tween the South Carolina Medical Association and
the South Carolina Workers’ Compensation Com-
mission, as well as a resource group to the commis-
sion as it attempts to fairly administer the
Workers’ Compensation Law of the State of South
Carolina.

192

Respectfully submitted,

Marion F. McFarland, III, M.D., Chairman

PEER REVIEW COMMITTEE

The Core Committee of the Peer Review Com-
mittee met once during the past year in order to
conduct a rehearing of a previous review which
we had performed under contract with the State
Health and Human Services Finance Commission.

Individual specialist members of our commit-
tee provided advice on coverage disputes between
SCMA members and insurers under the commit-
tee’s auspices.

The new PRO, Medical Review of North Caro-
lina, offered our committee the opportunity to
serve as the South Carolina Review Committee.
We recommended to the SCMA Board of Trust-
ees, who supported our decision, that we would
better serve our members in an oversight and
monitoring role with specific review and criteria
development performed directly by represen-
tatives of the S. C. Specialty Societies.

We welcome referrals from SCMA members
for committee assistance in disputes with insurers.

Respectfully submitted,

Edward L. Proctor, M.D., Chairman

PHYSICIANS ADVOCACY AND
ASSISTANCE COMMITTEE

The committee has been quite active this past
year. There have been a number of contacts with
physicians with impaired function and a number
of interventions by committee members resulting
in treatment and contractual arrangements with
impaired physicians. A significant number of
physicians who have been under contract and
monitored by the committee have completed
their term of supervision and have had their con-
tracts closed by the committee. Some of the physi-
cians who have completed their contracts have
become active members of the Physicians Ad-
vocacy and Assistance Committee. The commit-

The Journal of the South Carolina Medical Association

COMMITTEE REPORTS

tee has also been instrumental in influencing some
of the physicians with whom we have been work-
ing to become members of the SCMA.

The chairman met with the Board of Trustees
at the SCMA’s Annual Meeting in Charleston,
April 1988. The purpose was to inform the board
of the activities of the committee and to ask that
the name of the committee be changed to Physi-
cians Advocacy and Assistance Committee due to
the stigma of Alcohol, Drug Abuse and Impaired
Physicians Committee. The board approved the
name change. The chairman also met with the
Board of Trustees in January 1989.

The board once again approved a budget for
the Physicians Advocacy and Assistance Commit-
tee.

The part-time lab professional is doing an out-
standing job in the collection of urine screens.

The regional treatment teams continue to be
very active and continue to work with their peers
as an advocate. There are active Caduceus Club
physician groups in Charleston, Greenville-Spar-
tanburg, and Columbia areas and plans are going
forward for the establishment of such a group in
the Florence area to serve the Pee Dee section.

At the request of the Members’ Insurance Trust,
the committee developed criteria and guidelines
for the evaluation of treatment centers for physi-
cians impaired by alcohol or other substance
abuse. These criteria have been distributed to the
centers and to the Members’ Insurance Trust for
their use in the implementation of its insurance
program.

The chairman has met with the State Board of
Medical Examiners twice during the year enhanc-
ing the dialogue between the Board of Medical
Examiners and the committee.

The executive director of the State Board of
Medical Examiners met with the committee for
discussions of confidentiality.

The committee is working on a special issue of
The Journal dealing with chemical dependencies.
The committee is striving toward a July 1989
issue.

The chairman attended the ninth Annual Im-
paired Health Professionals Conference which
was held October 26-30, 1988 in Chicago.

The committee has developed dialogue with
the University of South Carolina School of Medi-
cine and its Peer Advocacy Committee. It is hoped

that in the coming year dialogue will open with
the Medical University of South Carolina’s Peer
Advocacy Committee.

I wish to thank the Board of Trustees, the
committee members and the SCMA staff for their
support and work this past year.

Respectfully submitted,

Hugh V. Coleman, M.D., Chairman

PUBLIC RELATIONS COMMITTEE

Public Relations activities were carried out dur-
ing 1988-89 with the committee’s approval of the
staff proposed plan. Highlights for the year in-
clude the following: 1) publicity on the amount of
charitable care provided by physicians; 2) pub-
licity on the SCMA’s expanded “Personal Care”
program which was designed to assist non-par-
ticipating physicians under Medicare better serve
their Medicare patients; 3) publicity on the
SCMA/SCMAA/SCIMER and Department of
Education’s health education van; 4) the develop-
ment of a new membership recruitment poster; 5)
conducting a media workshop at the annual Lead-
ership Conference; 6) publicity on hazardous
waste issues; and 7) publicity on health hazards of
tanning booths.

Staff has taken a more proactive stance with the
media this past year on the topics mentioned
above as well as with other topics including but
not limited to problems with Medicare, chiroprac-
tors, tort reform, the AMA’s proposed Registered
Care Technologist program, the PRO, teen preg-
nancy and healthy lifestyle issues. Staff has con-
tinued working for increased coverage in AM
News, assisting medical reporters on a weekly and
often daily basis, providing timely information
via “SCMA Newsletter,” expanding the SCMA
Library including the audio/ video loan service,
and scheduling physician speakers for interested
groups of organizations.

Staff has worked with several specialty societies
and committees on publicizing issues of concern
and has also worked with the medical student
sections in their endeavors to provide AIDS edu-
cation in the public schools as recommended by
the AMA. The SCMA participated in the red
ribbon campaign to promote a drug-free society

April 1989

193

COMMITTEE REPORTS

in addition to joining the AMA’s initiative for a
smoke-free society by the year 2000. We partici-
pated in public relations activities conducted by
the Highway Safety Office.

News clips on topics of interest and concern
have been regularly distributed to board mem-
bers. House of Delegates and Board of Trustees
position statements since 1972 are being compiled
for distribution later this year.

The committee continues to offer annual
awards for journalists exemplifying outstanding
reporting in the field of medicine. An award is
presented in each category of print, radio and
television media.

The Public Relations Committee is pleased
with the quantity and wide-spread distribution of
interest in association activities from media
throughout South Carolina. We expect to con-
tinue with our proactive relationship with the
media and look forward to good things happening
in the future. The committee encourages SCMA
members to consult our public relations staff for
advice and assistance in conducting PR activities
on the local level. Your comments and recommen-
dations are welcomed by staff.

Respectfully submitted,

Thomas C. Rowland, Jr., M.D., Chairman

SCMA/JUA PHYSICIANS RISK
MANAGEMENT COMMITTEE

This has been a good year for the Physicians
Risk Management Committee. We have had out-
standing success in our court cases involving med-
ical liability. We continue to have great support
for our programs from physicians and others over
the state. Two Risk Management workshops were
presented at the SCMA Annual Meeting last April
and one is planned for the meeting in April 1989.

South Carolina hosted the Annual Meeting of
the National Board of Medical Joint Underwriting
Associations in September at Kiawah Island. Our
committees’ efforts were highlighted during the
meeting and we were particularly pleased by the
kind remarks made by Dr. Tommy Rowland
when he addressed the meeting.

The highlight of our year has been the prepara-
tion and publication of the special January issue of
The Journal of the South Carolina Medical Asso-
ciation which was devoted entirely to professional

194

liability matters. This journal represents a mile-
stone for our committee, the Professional Liability
Committee and the SCMA. It will serve as a
permanent record of the purposes, the accom-
plishments to date and the future projections for
the PRMC. It is also a tribute to the concerted
efforts of many folks in South Carolina.

We take some measure of credit in the fact that
the JUA board has advised that there will be no
premium rate increase for the second year in a
row. Our intentions and our goals are to continue
our efforts to lower the medical liability risks in
our state as we maintain our campaign for effec-
tive risk management with all South Carolina
physicians and their staffs.

I want to express my appreciation for the dedi-
cation and hard work by each of our committee
members and for the efficient and effective help
given us by Joy Drennen who serves as our staff
support, the editor of our bulletin and our valu-
able adviser.

I would also like to acknowledge the superb
support we get from Cal Stewart and from Dr. Bill
Cantey who continues to provide excellent pre-
liminary chart review for us and contacts with our
area chairmen.

The committee plans to continue our efforts to
stress effective risk management and to impact
more and more favorably on medical liability in
South Carolina.

It has been a pleasure for me to continue to
serve as chairman of this very important com-
mittee.

Respectfully submitted,

Euta Colvin, M.D., Chairman

PRIMARY CARE/MEDICAID AND
INDIGENT CARE COMMITTEE

Problems associated with primary care, es-
pecially in rural areas, the lack of health insurance
for the indigent, and changes in the Medicaid
program which are designed to address these
problems, have received much attention during
the previous year at both the state and federal
level. Our committee has reviewed national rec-
ommendations such as those developed by the
AMA as well as existing programs and plans which
have been developed in our state.

One of our primary efforts has been to support
the expansion of the state’s Medicaid budget.

The Journal of the South Carolina Medical Association

COMMITTEE REPORTS

With a $3: $ 1 federal to state match, there is no
more cost effective way for South Carolina to seek
to improve health care than through the Medicaid
program. The Finance Commission, under the
direction of Andy Laurent, Ph.D., and through
our liaisons, Bob McRae and Kathi Peeples, has
been receptive to all our suggestions and even our
complaints. The commission is to be thanked for
the efforts to restore and improve physician reim-
bursement and for addressing our billing and
audit concerns. Any physician who claims he does
not accept Medicaid because of the red tape
should re-examine this decision. Our committee
and the Finance Commission will assure that if
you encounter any bureaucratic problems, we will
personally address them.

Barbara Whittaker of the SCMA staff main-
tains close communication with the Finance Com-
mission both on general policy matters and in
response to specific questions from physicians and
their office staffs. Gavin Appleby, M.D., con-
tinues to provide a physician’s viewpoint into
Medicaid decisions as the Medical Director of the
Finance Commission.

Special guests to our committee this past year
included Andy Laurent, Ph.D., Executive Direc-
tor of the Finance Commission. Dr. Laurent also
spoke at the SCMA Leadership meeting about the
millions of dollars that the federal catastrophic
health care law will cost in the state’s Medicaid
budget. Other guests to our committee were Mur-
ray Vincent, Ed.D., and Charles Johnson, MSPH,
who spoke to us about the successful project in
Bamberg County to reduce unintended adoles-
cent pregnancy. We were appreciative of the
success of this program and expressed our support
of other pilot programs similar to this. A. Baron
Holmes of the State Budget and Control Board
also attended this meeting of our committee, and
we enjoyed the opportunity to hear the types of
alternatives being discussed at this level of state
government.

We hope that the upcoming year will be as
successful as this past year in improving primary,
indigent, and Medicaid care in this state.

Respectfully submitted,

Benjamin E. Nicholson, M.D., Chairman

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April 1989

195

REPORT OF THE EXECUTIVE VICE
PRESIDENT

The year 1988 has been a particularly signifi-
cant one for the South Carolina Medical Associa-
tion. The increased interest of the physicians of
our state in organized medicine has swelled mem-
bership in the SCMA to a new high. The mem-
bership year ended with a total of 2,772 active
members (as compared to 2,631 in 1987), 100 new
members, 279 honoraries, 160 residents and 295
students — for a grand total of 3,606!

SOCPAC mirrored this growth, with a total of
1,012 members, an increase of 252 over 1987. In
the General Elections in November, 88 per cent of
the candidates supported by SOCPAC were suc-
cessful in their races. One race of particular note
was the House District 114 primary race where
two Republicans, incumbent John Bradley and
challenger John Rama, squared off. SOCPAC en-
couraged Mr. Rama to run and sent him to an
AMPAC candidate school which proved very ben-
eficial later in his campaign. With significant
financial support provided by SOCPAC, Mr.
Rama was successful in winning the seat from Mr.
Bradley who had held it since 1975.

The 1988 legislative session was successful as
well. The South Carolina Tort Reform Bill was
passed, reducing the statute of limitations on mi-
nors by seven years; increasing the standard of
evidence of punitive damage awards; retaining
contributory negligence; providing for attorney’s
fees for frivolous lawsuits; and establishing the
South Carolina Contribution Among Tortfeasors
Act. Coverage was obtained for state-employed
physicians under the SC Tort Claims Act, and the
Charitable Immunities Act was amended to make
clear that all charitable medical care is immune
from liability except where gross negligence or
willful misconduct can be proven.

Another measure of the success of our legisla-
tive activities is the fact that not a single bill
opposed by the SCMA got out of committee for
debate or a vote on the floor of the House or
Senate. The credit for this goes to our expanded
legislative staff and the increased participation in
the PAC. I would encourage those of you who are
not SOCPAC members to join so that we may
become even stronger in the political process in
the state.

We are now in the first year of the 108th
General Assembly and are faced with a number of

196

issues aimed at altering the way medicine is cur-
rently practiced in the state. We expect to see bills
introduced which will seek independent practice
by physical therapists, mandate health insurance
coverage for chiropractors, forbid dispensing of
drugs by physicians, approve the use of therapeu-
tic drugs by optometrists, change the definition of
the practice of nursing to eliminate physician
direction, and the list goes on and on. Try to
imagine where the profession would be if the
SCMA were not present at the State House looking
after your interests. Chances are you would hear
about most of these things after they were law and
too late to do anything.

For the first time in its history, the SCMA
adopted a Code of Ethics of its own, in the past
having relied on the Principles of Medical Ethics
of the American Medical Association. The new
SCMA Ethics Committee is to be commended on
its dedication to the formulation of this important
document.

Hard work by the SCMA Task Force on AIDS,
with input and assistance from the Ethics Com-
mittee, resulted in the development of AIDS pol-
icies which were subsequently adopted by the
House of Delegates.

SCMA publications were in the spotlight, with
the new Physicians' Guide to South Carolina
Law being furnished to all members and receiv-
ing many favorable comments on its usefulness.
The special issue of The Journal on teenage preg-
nancy in South Carolina was so widely circulated
that the supply of extra copies was completely
exhausted. Efforts of the SCMA to address the
many problems of inadequate prenatal care in-
cluded not only information in this special issue,
but also a survey of the state’s physicians in con-
junction with DHEC, with regard to their pre-
natal patient load.

The cooperative efforts of the SCMA, SCMA
Auxiliary, SCIMER and the Department of Edu-
cation have resulted in the purchase of a Health
Education Van for use in educating the students
(K-12) regarding more healthy lifestyles. At the
time this report is being written, the van is in
Chicago being equipped with three-dimensional
portable exhibits for use by the Department of
Education health educators in conducting classes
for school children. The van will also be available

The Journal of the South Carolina Medical Association

REPORT OF THE EXECUTIVE VICE PRESIDENT

after school hours for use by county medical so-
cieties, auxiliaries, private schools and other
groups.

With regard to SCMA concerns over the en-
vironment, particularly toxic waste, the House of
Delegates continued to endorse an end to the
acceptance of out-of-state toxic waste in South
Carolina and the potential health hazard of the
Pinewood landfill. A Task Force established dur-
ing the summer was charged with carrying out the
directives of the House. The SCMA Task Force
developed 14 recommendations which were pre-
sented to the DHEC Board. Included in the rec-
ommendations were the creation of a Division of
Waste Reduction, a study to determine the feasi-
bility of state ownership of all disposal facilities
and a ban on expanded or new incinerators.

The SCMA Committee on Continuing Medical
Education continued its efforts in 1988 to receive
full accreditation by the Accreditation Council on
Continuing Medical Education. The committee
was notified in mid-November that those efforts
had been successful, and the committee was com-
mended by the ACCME for having fulfilled all
directives given two years ago.

The 1988 House of Delegates directed the
SCMA leadership to “seek any and all means to
have the current PRO replaced by another PRO
and this directive was successfully carried out.
The PRO contract for South Carolina was
awarded to Medical Review of North Carolina
(MRNC) which now is the PRO for both Caroli-
nas. The early months of the new PRO’s operation
have been vastly different from the same time
period with the previous PRO. MRNC has two
South Carolina physicians on their Board of Di-
rectors and all reviewers and committee members
are being recruited, with the support of the
SCMA, from South Carolina.

In summary, “it’s been a very good year,” and
much of the success should be credited to the hard
work of the leadership and committees and the
active participation of many dedicated members.

On behalf of myself and the staff, we thank you
for affording us the opportunity to serve the phy-
sicians of South Carolina and we look forward to
continuing our efforts on your behalf.

Respectfully submitted,

William F. Mahon, Executive Vice President

SPECIAL REPORT ON THE IMPACT
OF TORT REFORM

As directed by the House of Delegates at the
1988 Annual Meeting, I am submitting this special
report on the initial impact of the Tort Reform
legislation enacted in 1988.

Since the legislation has been in effect less than
a year, it is not possible to demonstrate statistical
evidence of the impact. There are, however,
positive trends in the medical liability situation in
South Carolina of which some can be directly
attributed to tort reform while on others we may
only speculate.

The Patients’ Compensation Fund has ap-
proved a decrease in the rates for physicians who
have been members for four years from 40 per-
cent of the JUA premium to 30 percent of the JUA
premium. This reduction was effective on March
1, 1989.

The PCF also approved a 32 percent decrease
for state-employed physicians due to the one mil-
lion dollar cap enacted in the revisions to the Tort
Claims Act introduced by the SCMA.

The JUA has reduced the rates to the Free
Clinics operating in the state as a result of the
Charitable Immunity Act revisions enacted in
1988. This also was a SCMA sponsored bill.

The rates for the JUA liability insurance were
not increased this year and there is speculation by
the actuaries that a decrease may be possible next
year.

As you can see, there is a trend in South Caro-
lina that does not exist anywhere else in the coun-
try. Although tort reform is a factor, it is not the
only positive influence. The Risk Management
Program that is operated by the SCMA under
contract to the JUA is having an extremely
positive influence on the liability environment;
many thanks are due the physicians who volun-
teer their time to make the program work.

Respectfully submitted,

William F. Mahon, Executive Vice President

April 1989

197

REPORT OF THE SCMA DELEGATION TO THE AMA

The SCMA Delegation to the AMA has already
presented detailed reports of each AMA meeting
in appropriate issues of The Journal. This report,
therefore, will be only a brief summary of the
delegation’s activities.

The delegation has endeavored to present the
interests and concerns of SCMA members at the
national level by meaningful participation in vari-
ous AMA activities, including but not limited to
the meetings of the AMA House of Delegates. We
have taken to the AMA relatively few Resolutions,
but believe that they have been meaningful ones.
At the last Interim Meeting, our delegation sub-
mitted a Resolution (No. 70) in regard to Hospi-
talization Review Requirements of Self-insured
Companies. This was adopted by the House after
relatively minor changes. We were gratified that
Dr. Robert D. Burnett of California, member of
the Council on Medical Service and its former
Chairman, considered this to be the most impor-
tant Resolution submitted to the House.

One of the most important developments for
our delegation this year was the election of Randy
Smoak as Chairman of AMPAC. When Randy
was first appointed to the AMPAC Board by the
AMA Board of Trustees in 1984, we considered
this to be the result of a team effort by our
delegation, including a number of past delegation
members, notably Tucker Weston, Waitus Tan-
ner, and Harrison Peeples. I am sure that Randy
would be the first to emphasize this. However,
after he became a member of the AMPAC Board,
Randy clearly demonstrated the leadership qual-
ities with which we are all familiar, which led to
his election as secretary in 1986, and then to his
elevation to the chairmanship in 1988. We con-
gratulate him heartily on this and also thank him
for the important work that he did as Chairman of
our own SOCPAC, which showed remarkable
membership growth and effective political action

198

under his leadership.

There have been other leadership roles at the
AMA by members of your delegation. Dr. Walt
Roberts was elected to the Board of OSMAP (Or-
ganization of State Medical Association Presi-
dents) at the June 1988 meeting. John Hawk
completed his third term on the Council on Con-
stitution and Bylaws, and his second year as Chair-
man, at the 1988 Annual Meeting. At the Interim
Meeting he chaired the Convention Committee
on Rules and Order of Business, which among
other things was asked to bring in a special report
giving recommendations in regard to campaign
expenditures, hospitality, etc. This report was
adopted by the House. He also serves on the
Executive Committee of the Forum for Medical
Affairs which presents an important and infor-
mative program on Saturday afternoon at each
Interim Meeting.

As this report is written, the delegation has been
asked by the SCMA Board of Trustees to bring in
recommendations in regard to possible reduction
in delegation expenditures. The delegation is to
discuss this in a special meeting March 22, and
will include consideration of attendance by ac-
credited delegates to the various Section meetings
held in conjunction with meetings of the House of
Delegates.

The delegation expresses its appreciation to the
SCMA membership for the privilege of represent-
ing the SCMA at the AMA level. Again, we urge
that delegates to the SCMA House, and also any
members of the SCMA, give us your input and
participate with us in our deliberations at AMA
meetings. We would also like to express our sin-
cere appreciation for the splendid work of the
Auxiliary, who have made a notable impact at the
national level.

John C. Hawk, Jr., M.D., Chairman

The Journal of the South Carolina Medical Association

REPORT OF THE EDITOR OF THE JOURNAL

Next year will mark the 85th anniversary of
The Journal of the South Carolina Medical Asso-
ciation, one of the oldest of its kind. In the first
issue, the editors urged “upon every man the
importance of contributing his share. Today’s
editorial board strives to honor this founding phi-
losophy: ours should be a journal by and for the
South Carolina physicians, to the welfare of their
patients.

At this year’s Annual Meeting, the Thomas A.
and Shirley W. Roe Foundation Award will be
presented to a practicing physician for the article
judged to be in the best contribution during
1987-1988. To our knowledge, only the Neu:
England Journal of Medicine offers a similar
award. Our priorities for publication continue to
be (1) original contributions by practicing physi-
cians; (2) review articles by our state’s institution-
based physicians; and (3) information bearing
uniquely on the health care of South Carolinians.

We encourage SCMA members not only to
submit their original contributions, but also to

advise us of their preferences. Our cover will soon
have a new look. Do you like it0 What topics do
you suggest for special symposium issues0 And of
course, we also welcome letters to the editor.

On behalf of the entire Editorial Board, I again
thank Joy Drennen, our managing editor, for her
herculean efforts. State journals such as ours com-
pete for advertising resources with a myriad of
sleek, commercial publications commonly known
as “throwaways,” Ms. Drennen not only copy-
edits The Journal, but also spearheads our adver-
tising efforts. At the Annual Meeting, many of the
advertising booths will carry the announcement:
“We advertise in The Journal .” We encourage
members attending the Annual Meeting to visit
those booths and say, “Thank you.”

Finally, I thank the SCMA membership for the
privilege of serving you as editor.

Respectfully submitted.

Charles S. Bryan, M.D., Editor

REPORT OF THE SCMA MEMBERS’ INSURANCE TRUST

The SCMA Members’ Insurance Trust (MIT)
completed the last fiscal year with a surplus of
premium income over claims expense of $196,000.
Enrollment in the plan has grown from 1455 in
December of 1987 to 1736 at the end of 1988. This
20% increase in the plan demonstrates that we are
providing a service that physicians need at a price
they can afford.

The last increase in premiums was in February
of 1988 and at this time we do not anticipate
another increase until June 1989.

One of the major changes in the plan was the
moving of the claims processing activity from
Provident Life and Accident to the SCMA. The
first claims were paid in January with few diffi-
culties, and we expect that considerable econo-

mies will be achieved by this change. The plan is
now totally funded by the members and totally
administered by the SCMA.

I would like to express the sincere appreciation
of the MIT to Edward Mattison, M.D., who
finished his term on the Board of Directors this
past year. Ed was an outstanding president of the
Trust and the Trust prospered under his able
leadership.

The Trust remains in very good financial condi-
tion. and I am optimistic for the future.

I would like to express my sincere appreciation
to the members of the Board and the SCMA staff
for their hard work this past year.

Respectfully submitted,

Gerald A. Wilson, M.D., President

April 1989

199

REPORT OF THE SOUTH CAROLINA INSTITUTE FOR MEDICAL
EDUCATION AND RESEARCH (SCIMER)

The SCIMER has had one meeting this year at
which an outline of the year’s activities was dis-
cussed. We now have a fully constituted board of
12 members appointed for staggered terms thus
assuring that there will be continuity on the board
as well as the opportunity for new members and
new ideas.

The next meeting of the committee will be held
on Friday, April 28 during the Annual Meeting of
the SCMA. At that time we will hear the report of
our Scholarship Committee and make a final deci-
sion on the awards to be made at the House of
Delegates on the last day of the meeting.

This year there will be joint scholarship awards
with SCMAA to 10 students in each of our two
medical schools. The contribution by the upstate
cardiology group again makes it possible to award
scholarships to two upstate students. As has been
done for several years now, the Stuckey Schol-
arship will be awarded. This year we plan an
award for a medical student for the best research
project.

SCIMER made a cash award to the Health Van
project and we are most pleased to be associated

with the auxiliary in this innovative and most
valuable project. The SCMAA is to be com-
mended for its forethought, its persistence and its
hard work in getting this project accomplished.

Nancy Dickey, M.D., from Texas, will be the
speaker for the Leonard Douglas Memorial Lec-
ture at the House of Delegates on Thursday, April
27. She will speak on a subject related to medical
ethics. As was the case last year, we worked with
the Committee on Medical Ethics to secure Dr.
Dickey as our speaker.

SCIMER continues to receive and welcome
contributions to the scholarship fund, the Leonard
Douglas Memorial Fund and the general activities
fund. Contributions are tax deductible and will be
acknowledged as requested. I hope that each
SCMA member took advantage of the oppor-
tunity to contribute to SCIMER with the payment
of SCMA dues.

It has been my pleasure to again serve on the
SCIMER Board and as its president.

Respectfully submitted,

Euta M. Colvin, M.D., President

REPORT OF THE SOUTH CAROLINA POLITICAL ACTION COMMITTEE

The South Carolina Political Action Committee
has completed the 1988 year with a total of 1012
members.

SOCPAC and AMPAC assisted in the reelection
efforts of those legislators who share our philoso-
phy and ideals. In the November 1988 election,
we participated in 92 races, of which we were
successful in 80. Of the 12 races we lost, 4 were
incumbents.

On February 18, 1989, we held a “Key Contact
Seminar” at the Embassy Suites Hotel in Colum-
bia. The seminar is designed to instruct doctors
how to successfully deal with their legislators at
the State House and also in Congress. It is a
program put on by AMPAC.

We are looking towards the 1990 election of the

200

House of Representatives with the anticipation of
an increased membership in SOCPAC. We also
encourage SCMA members to participate in local
campaigns and actively support the candidate of
their choice.

The SCMA would like to formally congratulate
our past chairman of SOCPAC, Dr. Randolph
Smoak, on becoming chairman of AMPAC.

I would like to make note that our SOCPAC
luncheon speaker is Dr. John Zapp, D.D.S. Dr.
Zapp is the AMPAC lobbyist in Washington.

On behalf of the SOCPAC Board, I wish to
thank you for giving us the opportunity to serve on
this vitally important committee.

Respectfully submitted,

William M. Hull, Jr., M.D., Chairman

The Journal of the South Carolina Medical Association

REPORT OF THE SOUTH CAROLINA MEDICAL CARE FOUNDATION

The South Carolina Medical Care Foundation
has continued to provide retrospective case re-
view for insurance companies. Several hospitals
have also expressed interest in SCMCF review as
part of credentialling and Joint Commission
activities.

As president of the Foundation, I have been a
member of the PRO liaison committee (renamed
the Utilization Review Committee) of the South
Carolina Hospital Association. I have also been
appointed to serve on the Board of Directors of

Medical Review of North Carolina, the new PRO
for our state. I am encouraged by MRNC’s philos-
ophy and genuine desire to work with physicians
in our state.

If questions arise regarding PRO or review
activities by other organizations, the SCMCF of-
fers assistance and advice.

Respectfully submitted,

William J. Goudelock, M.D., President

REPORT OF THE SOUTH CAROLINA
AND ENVIRONMENTAL CONTROL

Development of a Strategic Plan — In early
1988 the department began a planning process
which culminated in both a strategic plan and a
strategic analysis for the department. The Strate-
gic Plan, approved by the board, describes the
department’s mission, management philosophy,
strategic issues and future directions. The Strate-
gic Analysis describes the department’s current
situation and reviews in detail the critical issues
the department faces. The plan and analysis have
begun to guide the organization, activities and
priorities of the department. One outcome so far
has been to increase the involvement of the pri-
vate sector in agency activities.

Hazardous Waste Task Force — The depart-
ment staffed the Hazardous Waste Task Force
and developed those task force recommendations
into statutory and regulatory form. The depart-
ment developed emergency regulations for ascer-
taining in-state “needs” for solid and hazardous
waste facilities.

Infectious Waste — The department worked
with legislators and private industry to address
potential problems with bio-medical waste. An
outcome was to develop revisions to solid waste
regulations strengthening landfill requirements.
The revisions would affect hazardous and bio-
medical waste disposal. The department devel-
oped draft regulations for infectious solid waste
management. In addition the department devel-
oped regulatory changes in air quality to incorpo-
rate commercial bio-medical waste incineration.

Infant Mortality — The infant mortality rate

DEPARTMENT OF HEALTH

has dropped for the sixth consecutive year to
(12.8/1000.) in 1987. A new initiative, “Part-
nership for Healthy Generations,’’ will focus
efforts to improve access to prenatal care in six
“anchor” counties which have the most excess
mortality.

Ad Hoc Obstetric Committee — The depart-
ment in a joint effort with the Hospital Associa-
tion, established a committee to study the obstet-
ric crises in the state. The South Carolina Medical
Association and other state agencies have been
actively involved from its initiation. As specific
problems are identified, the committee has sought
solutions. An example is the implementation of a
plan to increase obstetrics’ fees by using the de-
partment’s (DHEC) funds to “match” Medicaid.

Ad Hoc Pediatric Task Force — Building on the
success of the Obstetric Task Force, the depart-
ment, in a joint effort with the Hospital Associa-
tion and in cooperation with the South Carolina
Medical Association and other state agencies, has
established a Pediatric Task Force. This group has
begun the process of problem definition for pedi-
atric care.

Children with Hemoglobinopathies — In a spe-
cific area, newborn testing for hemoglobinopa-
thies, the department has completed its first
complete year of testing. Of the 59,255 tests run,
1,789 were found with sickle cell traits, 159 with
sickle cell disease and 43 with sickle-C disease.
Statistical testing was required by the Legislature
based on a cooperative study between the Medical
University of South Carolina and the department.

April 1989

201

DHEC REPORT

Newborns identified with sickle cell anemia are
followed by the Children’s Health Division and
placed in prophylactic antibiotic therapy unless
the family refuses services or the primary care
physician chooses a different approach.

Monitoring Health in South Carolina — In De-
cember, the department released a report docu-
menting the disproportionate poor health of black
South Carolinians compared to white South Car-
olinians and to black Americans. The department
has established a Minority Health Task Force
which is broadly representative of the community
and public and private organizations, including
the Medical Association, to develop a strategic
plan to close the gap. The Task Force will use
existing studies and reports as their foundation.

AIDS and HIV — An aggressive program of
education, counselling and testing and partner
notification has been instituted in the past year. In
January and February, 1988, a seroprevalence
study for HIV antibody was conducted in sexually
transmitted disease public health clinics. Sero-
prevalence was 2.35 percent among male patients
and 0.7 percent among females, 1.6 percent for
blacks and 1.4 percent for whites. The Bureau of
Laboratories is planning to make available tests to
allow physicians to monitor progress of the pa-
tients infected with HIV.

Licensure of Health Facilities — Regulatory re-
sponsibility for licensing birthing centers and resi-
dential treatment facilities for children and
adolescents was added in 1988. Standards for des-
ignation of Level II and III perinatal centers were
also developed and adopted. Revised Certificate

202

of Need regulations to implement the statute
passed in 1988 have been sent to the Legislature.
Efforts have been made through establishment of
working advisory committees to obtain input to
the development of new regulations prescribed by
the Certification of Need and Health Facilities
Licensing Act of 1988. The role of the paramedic
has been expanded to include the ability to
monitor drugs used in the transfer of critical pa-
tients which will enable better treatment during
extended transportation.

Center for Health Promotion — A center for
health promotion has been established to lead the
agency’s efforts to reduce the prevalence and
severity of risk factors associated with the state’s
leading causes of death. The center includes pro-
gram elements that were formerly located in the
Division of Chronic Disease and the Office of
Health Education. This new organization stresses
the importance of community-based prevention
efforts and provides a single agency focal point for
risk reduction programs and activities. For exam-
ple, the Florence Heart to Heart Program, which
is part of DHEC’s Cardiovascular Disease Preven-
tion Project, has implemented a variety of efforts
to increase public awareness of cardiovascular
disease risk factors. Community-wide campaigns
have focused on fitness, nutrition and smoking. A
recent “Quit and Win” contest attracted nearly
400 smokers who tried to quit smoking for a
month to become eligible for prizes donated by
local merchants.

Respectfully submitted,

Michael D. Jarrett, Commissioner

The Journal of the South Carolina Medical Association

REPORT OF THE S. C. STATE BOARD OF MEDICAL EXAMINERS

This past year has been a very active and effec-
tive year for the board. This report shall present a
brief statistical summary and review of the past
year.

Licensure — In 1988, this board issued 481 per-
manent licenses to physicians. This compares to
587 such licenses issued in 1987. Ninety of these
licenses were issued by way of the FLEX exam-
ination. Three hundred ninety-one were issued by
endorsement of credentials through the National
Board or other state boards. Of the 481 permanent
licenses issued, 20 were issued to graduates of
foreign medical schools. By way of comparison, in
1987 graduates of foreign medical schools re-
ceived 28 permanent licenses. Of the 481 perma-
nent licenses issued, 18 were issued to Doctors of
Osteopathy.

This board administered the FLEX examina-
tion in June and in December. In June, 20 appli-
cants took the exam; 17 passed and 3 failed. In
December, a total of 9 took the exam and all
passed.

Limited licenses are for residency training or
other special supervised practice environments
approved by the board. A limited license is for a
one-year period (July 1-June 30) or a part thereof.
A total of 285 limited licenses were issued in 1988.
Limited licenses were issued to 245 United States/
Canadian graduates; 40 limited licenses were is-
sued to graduates of foreign medical schools.

Nine new physician’s assistants were certified
by the board in the past year. There are 47 physi-
cian’s assistants licensed in South Carolina.

The medical directory of physicians licensed in
South Carolina was again printed in 1988. In the
1988-89 directory there were 5,388 physicians
listed practicing instate, and 1,448 licensed in
South Carolina but practicing out-of-state.

Investigatory and Disciplinary Activities — In
1988, the board received 135 complaints. This
compares to 124 received in 1987. Twenty-six (26)
orders were issued by the board during 1988.
These orders resulted in 2 revocations; 3 voluntary

surrenders; 4 indefinite suspensions; 3 suspensions
with fines; 1 public reprimand; 1 private repri-
mand; 10 agreements with conditions; and 2 li-
cense denials. These disciplinary cases include
sanctions for deviations from accepted standards
of practice, inappropriate prescribing, improper
supervision of a physician’s assistant, and sub-
stance abuse.

Legislative Changes — This past year, the Leg-
islature passed certain changes in the board’s
FLEX requirements, and a new SPEX examina-
tion for certain applicants was instituted. Minor
changes regarding certification of respiratory
care practitioners were also made.

Board Membership — Three board members
were re-elected to the board: R. Patten Watson,
M.D., of Columbia, representing the Second Con-
gressional District; James C. Holler, Jr., M.D., of
Rock Hill, representing the Fifth Congressional
District and James R. Edinger, D.O., representing
the osteopathic physicians at large.

Current officers and members of the board are:
J. Ernest Lathem, M.D., President (re-elected as
president 1/89); Spencer C. Disher, Jr., M.D., (re-
elected as vice-president 1/89); R. Patten Watson,
M.D., (re-elected as secretary 1/89); Vernon E.
Merchant, Jr., M.D.; James C. Holler, Jr., M.D.; C.
Dayton Riddle, Jr., M.D.; Mrs. Esther H. Tecklen-
burg; James S. Garner, Jr., M.D.; James R. Edin-
ger, D.O.; Stephen I. Schabel, M.D.

Current members of the Medical Disciplinary
Commission are: John A. Ouzts, III, M.D.; Jack A.
Evans, Jr., M.D.; Alan W. Fogle, M.D.; W. Wal-
lace Fridy, Jr., M.D.; Charles J. Owens, M.D.;
Donald G. Gregg, M.D.; C. Alden Sweatman, Jr.,
M.D.; Robert E. Lee, M.D.; Bryan L. Walker,
M.D.; James L. Maynard, M.D.; Boyce M. Law-
ton, Jr., M.D.; Joseph W. Dunlap, Jr., M.D.; James
E. Bleckley, M.D.; Daniel M. Ervin, M.D.; James
M. Rainey, M.D.; Martin H. Zwerling, M.D.

Respectfully submitted,

J. Ernest Lathem, M.D., President of the Board

April 1989

205

RESOLUTIONS

SUBMITTED BY: South Carolina
Thoracic Society

SUBJECT CLEAN INDOOR ACT

W HERE AS, Sufficient data are now available
to support the report of the Surgeon General of
1986, “The Health Consequences of Involuntary
Smoking,’’ which clearly identifies the health is-
sues, including lung cancer, associated with the
involuntary inhalation of environmental tobacco
smoke; and

WHEREAS, It is long overdue that this legisla-
tion be adopted to protect the rights of the vast
majority of the citizens of South Carolina who are
non-smokers; therefore, be it

RESOLVED; That the SCMA strongly endorse
the passage of S. 138 to enact the Clean Indoor Air
and Promotion of Public Health Act of 1989 and
to provide penalties and violations.

SUBMITTED BY: South Carolina Chapter of
American Academy of
Pediatrics

SUBJECT: CORPORAL PUNISH-

MENT IN SCHOOLS

WHEREAS, Recent educational, psychologic
and psychiatric literature continues to accumu-
late evidence in opposition to corporal punish-
ment in schools; and

W HERE AS, Events of misuse and abuse are
associated with administration of corporal punish-
ment and the American Academy of Pediatrics
has encouraged alternative methods for imple-
mentation of self-control and responsible behav-
ior; therefore, be it

RESOLVED; That the South Carolina Medical
Association urge all Legislators, school board
members, educators, parents and other adults
within South Carolina to seek the abandonment of
corporal punishment and its legal prohibition
within the educational system.

SPECIAL GUEST: JOHN LEE CLOWE, M.D., SPEAKER,

HOUSE OF DELEGATES, AMERICAN MEDICAL ASSOCIATION

John Lee Clowe, M.D., a family practitioner
from Schenectady, New York, was elected to
serve his second term as Speaker of the AMA
House of Delegates in June, 1988. He had served
as Vice Speaker 1984-86, and as a Delegate from
the Medical Society of the State of New York and
Chairman of its Delegation from 1980 to 1984.

Doctor Clowe began his service to organized
medicine in 1963 as a Delegate to the Medical
Society of the State of New York from Schenec-
tady County Medical Society, and is a Past Presi-
dent of that Society. He became Vice Speaker of
the House of Delegates of the Medical Society of
the State of New York in 1979 and served as
Speaker of that House from 1980 until his election
to the AMA Board. He is a member of the Board of
Directors of the New York Medical Political Ac-
tion Committee and on the Executive Committee
of the Medical Liability Mutual Insurance Com-
pany. Doctor Clowe is a member of the Institute
of Parliamentarians, and also Chairman of the

206

Nurses Advisory Council at Ellis Hospital School
of Nursing in Schenectady.

Doctor Clowe received his M.D. degree from
Albany Medical College-Union University, Al-
bany, New York, and took his internship and
residency at Ellis Hospital in Schenectady. He is a
Diplomate of the American Board of Family
Practice and a Charter Fellow and member of the
American Academy of Family Physicians. He is a
Past President of the American Academy of Fam-
ily Physicians, Schenectady County.

Doctor Clowe is an Attending in Family Prac-
tice at St. Clare’s and Ellis Hospitals in Schenec-
tady and an Attending in Medicine at Ellis
Hospital. He is an Associate in Medicine at the
Albany Medical College in Albany, Chief School
Physician of the City of Schenectady, and Health
Officer of the Town of Niskayuna.

Doctor Clowe and his wife, Marion, reside in
Schenectady.

The Journal of the South Carolina Medical 'Association

SOCPAC LUNCHEON SPEAKER: JOHN S. ZAPP, D.D.S., DIRECTOR
OF GOVERNMENT AFFAIRS, AMERICAN MEDICAL ASSOCIATION

Guest speaker for the SOCPAC luncheon on
Saturday, April 29, will be John S. Zapp, D.D.S.,
Director of Government Affairs for the American
Medical Association.

Dr. Zapp is a native of Nampa, Idaho, who was
educated at Boise College and the Creighton Uni-
versity School of Dentistry in Omaha, Nebraska.
He did postgraduate studies in Dentistry at the
Universities of Washington and Oregon and in
Political Science at Portland State College. He
then entered the private practice of Dentistry in
The Dalles, Oregon, and later in Portland.

Prior to his position of Director of Government
Affairs for the AMA, he served as Director of the
AMA Department of Congressional Relations and
later as Director of the AMA Washington Office.
He has also served as Deputy Assistant Secretary
for Legislation (Health) in the Department of

LEONARD W. DOUGLAS, M.D.,
“MEDICAL ETHICS: WHERE DO
NANCY WILSON DICKEY, M.D.

Health, Education and Welfare, Deputy Assistant
Secretary for Health Manpower, Special Assistant
of Dental Affairs and Federal Representative to
the Liaison Committee on Medical Education.

Dr. Zapp’s honors include citations as one of
Oregon’s “Ten Outstanding Young Men,’’ the
Distinguished Service Award “Young Man of the
Year,” Honorary Doctor of Science Degree from
the College of Medicine and Dentistry of New
Jersey, and Special Citations from the Secretaries
of HEW, Elliott L. Richardson and Casper W.
Weinberger. He is an Affiliate Member of the
AMA and the American Association of Clinical
Urologists.

Dr. Zapp served his country as a member of the
United States Marine Corps, receiving a Purple
Heart in the Korean War.

MEMORIAL LECTURE:
THEY COME FROM?"

Dr. Dickey is a member and former Chairman
of the AMA Council on Ethical and Judicial
Affairs. A Diplomate of the American Board of
Family Practice, she is currently an Associate
Professor in the Department of Family Practice at
the University of Texas Medical School at
Houston.

Dr. Dickey received her undergraduate educa-
tion at Stephen F. Austin State University and her
M.D. Degree from the University of Texas Medi-
cal School at Houston. Her honors and awards
include Alpha Omega Alpha at the University of
Texas Medical School at Houston; Chief Resident,
Memorial Hospital, Department of Family Medi-
cine, Houston; Who’s Who in American Colleges
and Universities, 1975 ; and Distinguished Alum-
ni, University of Texas Medical School at
Houston, 1987. She holds positions on the Edi-

torial Advisory Board of Medical World News
and Patient Care, and has also served on the
Editorial Advisory Board of Medical Ethics
Advisor.

Dr. Dickey has served her community as a
member of the Board of Directors of The Hastings
Center, the Office of Early Childhood and Devel-
opment, and the American Heart Association,
Fort Bend County Chapter. Active in St. John’s
United Methodist Church, she has also partici-
pated in school district activities and has been a
member of the Richmond/Rosenberg Chamber
of Commerce.

A well-known speaker on topics pertaining to
medical ethics, she is also the author of the Hast-
ings Center Report (1987) and Courtland Forum
(1988).

April 1989

207

For several years, AIDS has held center stage at our annual meeting. This year will probably be an
exception, although a scientific session will deal with specific aspects of the management of HIV
infection.

In last month’s issue of The Journal, the results of a seroprevalence study of inpatients at the James F.
Byrnes Medical Center — a facility of the Department of Mental Health — were reported. Approx-
imately one of every 25 patients from the Department of Corrections, one of every 100 patients from the
Detoxification Program, and one of every 400 Mental Health inpatients were HIV-positive. In the
editorial below, Dr. Arthur F. DiSalvo outlines a program for screening newborn infants for HIV
antibody.

While of great interest, such seroprevalence studies demonstrate why we must now regard everybody
as potentially HIV -infected and therefore use universal precautions.

— CSB

NEWBORN SCREENING FOR HIV ANTIBODY

On January 31, 1989, the Bureau of Laborato-
ries received a grant of $263,000 for 1989 to
anonymously screen all newborns in South Caro-
lina for evidence of HIV antibody. The grant is
renewable for four additional years.

In 1987, the Centers for Disease Control (CDC)
initiated a group of studies referred to as the
“Family of HIV Sero-Prevalence Surveys” to de-
termine the extent and monitor the spread of HIV
infection in various segments of the population.
One of these surveys involved testing specimens
from neonates for evidence of HIV infection. This
testing of the newborn is an acceptable surrogate
to determine the sero-prevalence of HIV in child-
bearing women and an indirect method of assess-
ing HIV penetration into the heterosexual pop-
ulation. In addition, it is possible to chart the
geographical and temporal trends of this disease
in our society using this study population.

CDC implemented these surveys in 30 cities in
the United States: 20 high-risk cities and ten low-
risk cities. Initially, no city in South Carolina was
selected. In 1988, the CDC asked us to develop a
proposal which would permit South Carolina to be
included in the study. In September of 1988, the
Bureau of Laboratories sought funding which
would be used to screen virtually all of the neo-
nates in the state for evidence of HIV infection.
South Carolina is presently screening for phe-
nylketonuria (PKU), hypothyroidism, and hemo-

208

globinopathies. Testing would be accomplished
using specimens collected and submitted to the
Bureau of Laboratories for this screening and
would not require the inconvenience for the pa-
tient, physician or health care provider of obtain-
ing an additional specimen.

The CDC grant has two absolute restrictions:
the HIV sero-prevalence study must not interfere
with the newborn screening for metabolic diseases
and the results must be irrevocably separated
from all information which may directly or indi-
rectly identify the patient. A computer program
has been designed so that after completion of all
routine newborn metabolic disease testing, a new
file will be created for use in HIV testing contain-
ing only general demographic data about the
mother (age, race, county of residence). The new
data file will be used for all subsequent HIV-
related work and the blood spot specimens used in
HIV testing will be separated from the request
form to avoid even inadvertent correlation of HIV
results and patient identification. As an added
security precaution, HIV testing will be per-
formed by different personnel and at a separate
site from routine screening for metabolic diseases.

In December 1988, the House of Delegates of
the American Medical Association (AMA) passed
Resolution Number 9. Recognizing that most state
public health laboratories already routinely tested
blood from newborns, and that technology is

The Journal of the South Carolina Medical Association

available to determine HIV antibody from these
specimens, this Resolution urges state health de-
partments, in states with a high prevalence of
neonatal infection, to add HIV testing to the new-
born screening. The AMA states that this action is
justified because earliest possible identification is
important for counseling, partner tracing, infant
care and recognition that an infected mother may
be breastfeeding an uninfected infant.

At present, South Carolina is not considered as a
state with a high prevalence of HIV in the new-
born. However, any physician who wishes to have
infant patients tested for HIV and receive the
results, as suggested by the AMA resolution for
high prevalence states, may request these tests
from the Bureau of Laboratories. HIV testing
with identification may be obtained by collecting
a specimen similar to that used for metabolic
disease screening and submitting the specimen
accompanied by the appropriate laboratory form.
Additional information can be obtained by tele-
phoning the laboratory (737-7002).

More recently, on February 8, 1989, the Na-
tional Research Council, an affiliate of the Na-
tional Academy of Sciences, released a major
report on the AIDS epidemic. The commission
chairman, Dr. Lincoln Moses, recognizing that
many states now routinely test newborn babies
anonymously for HIV antibody, recommended
that anonymous testing should be extended to all
newborns. South Carolina will implement this

recommendation by July 1, 1989.

It may be asked why a state such as South
Carolina, with a relatively low prevalence of neo-
natal HIV infection, should participate in a sero-
prevalence survey. The relatively low incidence
of HIV in the heterosexual and, hence, in the
neonatal population of South Carolina is precisely
why the participation of states such as South Caro-
lina is so critical. States with a relatively high
prevalence of neonatal HIV are beyond the point
where they can provide epidemiologic data about
the early stages of HIV spread in the heterosexual
population. If there is complacency regarding
HIV transmission in the heterosexual population
of South Carolina, data derived from this study
could stimulate individuals to reduce their risk
behavior.

In conjunction with CDC, the Bureau of Labo-
ratories plans on the periodic release of informa-
tion as it is gathered in the course of this sero-
survey.

Arthur F. DiSalvo, M.D.

Chief, Bureau of Laboratories

William B. Gamble, M.D.

Chief, Bureau of Preventive Health Services

South Carolina Department of Health and
Environmental Control

Box 2202

Columbia, S. C. 29202

It is customary to preface guest editorials with the disclaimer that the opinions expressed may not
reflect the views or positions of the South Carolina Medical Association. Although the following is not a
guest editorial, this disclaimer should also apply. These viewpoints are my own.

— CSB

PEER REVIEW WHERE IT COUNTS

Although we spent four years together in the
same institution, I do not recall exchanging pleas-
antries with Ralph (not his real name) on even a
single occasion. Something about him seemed in-
stinctively unpleasant, bordering on the malev-
olent. Now, 22 years later, I fully understand why
I never went out of my way to break the silence.
Called to testify at a court trial in which I saw not
the faintest hint of malpractice, I asked the de-
fense lawyer: “Whom did the plaintiff’s lawyer

find to testify?” The answer: Ralph. Some re-
search disclosed that Ralph had testified against
nearly 50 physicians throughout the United States
in recent years. Need a plaintiff’s witness? Call
Ralph.

The awarding of $21.75 million to Rock Hud-
son’s HIV antibody-negative lover illustrates that
anything can happen when matters are decided
by American juries. There is wide agreement that
our trial-by-jury tort liability system is especially

April 1989

209

poorly suited to medical negligence cases. Still, we
must function with this system until a better one
comes along. Some plaintiffs have legitimate
grievances, and it is therefore essential that physi-
cian witnesses be found to support their cases. My
purpose here is not to dispute the legitimacy of
such testimony when the theory of negligence
centers around well-established principles of
practice or standards of conduct. Rather, my pur-
pose is to question the ethical justification of zeal-
ous advocacy on behalf of plaintiffs in questions of
opinion, judgment, or skill in which equally
knowledgeable and conscientious physicians
might have acted differently. However outland-
ish, such testimony suffices to bring the matter
before a jury. Irrespective of the outcome, such
cases do incalculable damages both to the physi-
cian defendants and to society.

Plaintiffs’ attorneys seem to have an increasing-
ly easy time locating physicians such as Ralph who
are ready and eager to testify in dubious or bor-
derline cases. It is no secret that legal testimony
pays well. Some of the witnesses, such as Ralph,
are private practitioners, while others number
among the elite of academic medicine. Many are
paid by brokerage firms which receive a con-
tingency fee of 20% to 30% for favorable verdicts. 1
Many of these witnesses seem — like some plain-
tiffs’ lawyers — to accept an unfortunate outcome
as prima facie evidence of malpractice.

What is most bothersome about this testimony
is that the witnesses seem to forget the wisdom
expressed in the first aphorism of Hippocrates:
judgment is indeed difficult. The same can be said
of surgical skill; recall that even the great J. Mar-
ion Sims described in his autobiography a pa-
tient’s death due to inadvertent ligation of both
ureters. When the day comes that neither clinical
judgment nor skill figures into the equations that
determine outcome, our profession will be ob-
solete. But then — it’s arguable whether physicians
such as Ralph have much of a concept of what we
mean by profession.

I suggest the following desiderata:

1. Medical organizations — both umbrella so-
cieties such as ours and specialty societies — should
establish standards pertaining to ethical testimony
on behalf of either plaintiffs or defendants. Due to
its importance to the court, such testimony should
never reflect shades of opinion in matters in which
equally well-trained, well-read, and diligent phy-
sicians might disagree. Rather, such testimony

210

should be easily justified by the preponderance of
medical thought as expressed in textbooks and/or
by well-established standards of practice.

2. Medical organizations should establish a
mechanism for evaluating complaints about phy-
sicians’ testimony, whether based on individual
instances which seem highly questionable or on
frequent testimony which seems of marginal va-
lidity. Testimony which is clearly irresponsible, or
frequent testimony which is highly questionable
in most instances, should be grounds for probation
or dismissal from such organizations. Irresponsi-
ble testimony should also be grounds for revoka-
tion of hospital staff privileges and medical
licenses.

3. Medical organizations and teaching institu-
tions should develop qualifications requisite for
their members to testify in court. No physician
should be allowed to testify in medical negligence
cases — either for plaintiffs or defendants — with-
out first demonstrating a knowledge of (a) the
basis for theories of negligence; (b) the “deep
pocket” approach and hence the need to discern
among multiple alleged joint tortfeasors; (c) the
pivotal role of the expert witness; (d) the re-
ciprocal nature of the physician-patient contract;
(e) the potential for devastating consequences of
malpractice litigation on the lives of physicians
and their families, even when the defense ulti-
mately prevails; (f) the cost of malpractice litiga-
tion to society; and (g) one’s own fallibility.

4. Hospital staffs should develop more mean-
ingful peer review mechanisms, including the
willingness to advise colleagues of instances in
which retrospective chart review suggests — yes —
malpractice. Although the situation is improving,
too often in the past the discovery of apparent
malpractice has left committee members stutter-
ing: “Who will bell the cat?” Legislation should
protect the findings of peer review committees
from the legal discovery process. It has been the
failure of our own peer review mechanisms, plain-
tiffs’ lawyers might contend, that has created
what we perceive to be a crisis of malpractice
litigation in the first place.

What does it mean to be a member of the
medical profession? In today’s era of specialties
and subspecialties, it is the umbrella organizations
such as the county societies, the SCMA, and the
AMA which best provide the answers. I suspect
that persons such as Ralph, who seem willing to
slam wrecking balls into the lives of their col-

The Journal of the South Carolina Medical Association

leagues for their own financial gain, often con-
sider our organizations to be meaningless. To be a
professional means to set high standards for
oneself; to be a member of a profession means to
adhere to standards set by colleagues. To set stan-
dards for court testimony just as we improve
standards for the peer review of our art and sci-

ence would seem to be in the dearest interests of
our litigious society.

— CSB

REFERENCE

1 . Doctors seek crackdown on colleagues paid for testimony in
malpractice suits. The Wall Street Journal, November 7,
1988.

ON THE COVER: THE GERMAN FRIENDLY SOCIETY
SCMA FIFTH ANNUAL MEETING

Featured on this month’s cover is an architect’s
rendering of the original Hall of the German
Friendly Society, site of the fifth Annual Meeting
of the South Carolina Medical Association in 1853.
This building was built in 1801 on Archdale Street
(across from St. John’s Lutheran Church) and
burned in 1864. Earlier meetings of the Associa-
tion had been held at the Apprentices’ Library,
the Temperance Hall and Market Hall. Of these,
only the Market Hall is still standing, and we have
been unable so far to locate pictures of the other
two.

The fifth Annual Meeting was convened on
January 31, 1853, with Dr. Eli Geddings, Presi-
dent, in the chair. There were only 37 members
present for the opening session. Members of the
Colleton District Medical Association applied for
and were granted a charter and its members duly
elected members of the Association.

The Treasurer, Dr. W. T. Wragg, reported a
deficit of approximately $250 in the treasury,
caused by the failure of the members to pay their
dues. “The amount of yearly contribution is so
small [$5] that it cannot be inconvenient to a

member, at any time, to pay up the sum. Their
dilatoriness must, therefore, arise from want of
consideration. . . . The evil is great.” It was, “Re-
solved, That the Treasurer be authorized to ap-
point a collector for the country with the usual
compensation, to collect arrears due the Asso-
ciation.”

The committee on Registration of Births, Mar-
riages and Deaths reported that they were again
memorializing the Legislature to establish a sys-
tem of registration.

The Annual Address by Dr. Emory Coffin of
Aiken, “Observations on the Influence of Climate
in Tubercular Disease,” was postponed so that the
association members could attend the funeral of
Dr. W. G. Ramsey and so that the Dean of the
Medical College could invite the medical students
to attend the lecture.

After several other reports, discussions, and ad-
dresses, there being no further business before the
Association, it adjourned.

— Betty Newsom

The Waring Historical Library

April 1989

211

SOUTH CAROLINA MEDICAL ASSOCIATION

AUXILIARY

REPORT OF THE PRESIDENT OF THE SCMA AUXILIARY
TO THE 1989 SCMA HOUSE OF DELEGATES

The 1988-1989 year began with a theme, “Bright Ideas — TOGETHER We Can Make Them Happen.
By our working TOGETHER to make our IDEAS become reality, many goals have been reached, and our
communities will benefit from the results for years to come.

THE HEALTH EDUCATION VAN: The HEV is now in operation after two years of careful planning
and fund raising. Mrs. Lewis Terry (Betsy), HEV Chairman, has spent countless hours on this project, and
to her we are very grateful. Our appreciation is extended, also, to SCMA, SCIMER, the S. C. Department
of Education, county medical societies and auxiliaries, and to the many auxilians and other individuals
who contributed to the HEV project. The HEV provides opportunities to teach health education to South
Carolina school children, for teacher training, workshops, staff development and health programs for
adults. The following areas will be taught by two health educators: nutrition, alcohol and drug awareness,
life begins, and personal health.

HEALTH PROJECTS: The commitment to improving the quality of life in South Carolina through
numerous health projects has been maintained. Auxilians have been involved in many health related
activities: personal awareness programs (mammogram month, pap smear month, cholesterol check
month, physical for spouse month, and physician fitness month); pre-school vision screening; hospice;
child abuse shelters; Camp Kemo Scholarship; Special Olympics; nursing and medical student schol-
arships; indigent care; teen center support; and substance abuse are some of the many programs.

The topics discussed at the “1989 Focus On Health” program during the Winter Board Meeting were
Adolescent Health, The Importance of Cholesterol Testing and Nutrition, Building Children’s Self
Esteem, and Update on AIDS in S. C. All the speakers were physicians’ spouses, and their presentations
were outstanding. Cholesterol testing was provided free by Providence Hospital Heart Institute. The
exhibits were very informative and visited by many of our auxilians. This program was perfectly planned
by Mrs. Robert Galphin (Linda) and Mrs. Eugent Schwarz (Laurie), Health Projects Chairmen.

MEMBERSHIP: Under the direction of Mrs. Birnie Johnson (Virginia), Membership Chairman, all non-
auxilians (including military spouses) have been invited and encouraged to join the auxiliary. As an effort
to attain more members, two membership campaigns were held during the year. Many resident
physician/medical student spouses have been sponsored by auxilians. Creating interest during the training
years will provide a smooth transition during the practice years.

The physicians spouses in Cherokee County voted to reorganize the Cherokee County Medical
Auxiliary. We welcome them into our organization.

To build up membership in their counties, the presidents of Florence and York counties offered a
membership challenge.

Virginia’s interest and enthusiasm will surely be reflected in our final total of members.

AMA-ERF: For more than 30 years, the SCMA Auxiliary has continued to support medical education
and research. A goal of $25,000 for this year has been set by Mrs. David Cook (Rosemary), AMA-ERF
Chairman. Many fund raising events by the counties and by the state will assure the committee’s goal to
promote continued quality medical education and quality medical care for all.

Christmas Sharing Cards by the counties bring in a very large percentage of money for AMA-ERF, and
SCMA Auxiliary Executive Board’s Valentine Sharing Card contributed much towards this fund. The state
committee is also sponsoring a quilt raffle. The winner will be drawn during the luncheon at convention.

Checks representing all auxiliary contributions will be presented to the deans of the state’s medical
schools at the SCMA House of Delegates.

LEGISLATION: Auxilians and their spouses were encouraged to register to vote and to vote in the
November 1988 election. Many auxilians were actively conducting voter registration at hospitals and

212

The Journal of the South Carolina Medical Association

EDITORIALS

involved in working for candidates who best promote the interest of the medical profession.

A very informative legislative workshop was held in September which was planned by the Legislative
Chairman, Mrs. Charles Duncan (Pat). In March, a “Day at the Legislature” will be attended by many
auxilians.

SOCPAC: Membership has been encouraged during my county auxiliary visits. Letters and reminders
stressing the importance of SOCPAC membership were mailed to all auxilians.

Two members of the auxiliary serve on the SOCPAC Board.

EXECUTIVE BOARD MEETINGS: During the Spring Board Workshop in May, at roundtable
discussions, the retiring officers and committee chairmen shared their expertise with incoming officers
and chairmen. Speakers from health-related organizations made brief talks and provided exhibits.

Dr. Thomas C. Rowland, Jr., President of SCMA, and Mr. William Mahon, SCMA Executive Vice
President, brought greetings from SCMA and gave an update on its activities. Mrs. Mark Whittaker
(Barbara), SCMA Auxiliary Staff Director, reported on the Personal Care program.

The Fall Executive Board Meeting was held in October, and excellent plans for the year were given by
the officers, committee chairmen, and the county presidents. Dr. Rowland was the featured luncheon
speaker. Dr. Katy Wynne, Health Education Van Educator, was introduced and spoke briefly.

During the Winter Board Meeting, brief reports were given by a few committee chairmen. Special
luncheon guests were Dr. Rowland and Mr. Mahon. Miss Ann Slater, S. C. Department of Education
Health Consultant, was the luncheon speaker.

DOCTOR’S DAY: Doctors’ Day is a project promoted by Southern Medical Association Auxiliary. It is
the goal of Southern to include awareness of breast disease and the good results of mammography in each
county in connection with Doctors’ Day. In honor of Mrs. David Thibodeaux, who underwent a double
mastectomy last summer, physicians’ spouses are being encouraged to have a mammogram.

Many activities are being planned in honor of doctors on March 30.

PHYSICIANS’ FAMILY SUPPORT: Support groups are being formed to help physicians’ families
through difficult experiences. These services can range from help with a new baby to transportation to
referral to a spouse’s treatment team member. A training seminar on April 6, 1989, is being planned by
Mrs. M. E. Borgstedt (Kaye), Chairman of the Physicians’ Family Support Committee. TOGETHER We
must support our physicians’ families.

SCHOLARSHIPS: Annually, SCIMER and the SCMA Auxiliary award ten scholarships to worthy
medical students based on merit and need. These scholarships will be presented during the SCMA House of
Delegates.

SCMA LEADERSHIP CONFERENCE: We appreciate the SCMA’s invitation to auxilians. Six auxilians
were in attendance at this year’s outstanding conference.

SCHOOL NURSES’ WORKSHOP: The SCMA Auxiliary was pleased to co-sponsor the Eighth Annual
School Nurses’ Workshop with the S. C. Department of Education and DHEC. Nurses from schools
throughout S. C. attended this very informative workshop. A Health Education Van update was given
during the luncheon.

SCAN/ JOUBNAL PAGE: The S. C. Auxiliary News (SCAN) was published three times during the
year. The auxiliary page of The Journal of the South Carolina Medical Association has been written
monthly by state officers and committee chairmen. The Auxiliary is very proud of this privilege as it serves
as a fine vehicle in communicating with our spouses’ organization.

AMA AUXILIARY MEETINGS: SCMA Auxiliary members were represented at the following meet-
ings in Chicago: AMA Auxiliary Annual Convention was attended by six delegates and by the presidential
delegate. Also attending from South Carolina were Mrs. Wayne Brady (Billie), AMAA Past President, and
Mrs. Perry Davis (Sheila), AMAA Bylaws Chairman. The SCMA Auxiliary President and five county
presidents-elect attended Confluence I in October 1988. Attending Confluence II in February 1989 were
the SCMA Auxiliary president-elect, the nominated president-elect, and four county presidents-elect.

SCMA: The SCMA Auxiliary appreciates the support and guidance given by the SCMA. The assistance
and advice of the SCMA has been essential to the accomplishment of auxiliary goals. We thank Dr.
Rowland and Mr. Mahon for attending our Executive Board Meetings and giving SCMA updates, and we
thank the SCMA Board of Trustees for the opportunity to attend the board meetings. The auxiliary is
appreciative of the opportunity to serve on nine SCMA committees.

The Auxiliary is very grateful to SCMA for the services of Mrs. Mark Whittaker (Barbara) and the
SCMA staff. Barb’s expertise and willingness to help ALL auxilians have been an immense service to the
auxiliary. She has attended our meetings faithfully and has offered excellent suggestions ahd help. I am
most fortunate to have Barbara assist me in my presidential duties.

Respectfully submitted,

Mary James (Mrs. Stanford)
President, SCMA Auxiliary

April 1989

213

EXHIBITORS FOR 1989 ANNUAL MEETING

Miles Inc. Pharmaceuticals

32, 33. Winchester Surgical Supply Company

Abbott Laboratories

34.

U. S. Army Health Professional Support

Glaxo Pharmaceuticals

Agency

BioAnalogics, Inc.

35.

Fenwick Hall Hospital

Burroughs Wellcome Company

36,

37. The G Geisler Group

Colleton Regional Hospital Rehabilitation

38.

Lancaster Recovery Center

Care Unit

39.

S. C. Medicaid

Merck Sharp & Dohme

40.

Shepherd Spinal Center

Roche Biomedical Laboratories, Inc.

41.

American Heart Association, S. C. Affiliate

Navy Medical Programs

42.

Refreshments

10.

Southeastern Hospital Supply

43.

Carolina Physicians Advisory Service

11.

Palisades Pharmaceuticals

44.

Roerig-Pfizer

12.

Mead Johnson Nutritionals

45.

Premier Marketing

13.

Bristol Laboratories

46.

McNeil Consumer Products Company

14.

Charter Rivers Hospital

47.

Health Images, Inc.

15.

Genentech

48.

The W. B. Saunders Company

16.

S. C. Department of Health &

49.

U. S. Air Force

Environmental Control

50.

The Upjohn Company

17.

IC System, Inc.

51.

Lederle Laboratories

18.

Wyeth Laboratories

52.

Sandoz Pharmaceuticals

19.

Parke-Davis

53.

The Computer Store

20.

The Medical Protective Company

55.

Popcorn

21.

Boehringer-Ingelheim Pharmaceuticals,

63.

Carolina Medical Review

Inc.

64.

MUSC Alumni Affairs

22.

Refreshments

65.

Adria Laboratories

23.

Pfizer Laboratories

66.

Disability Determination Division, S. C.

24.

S. C. AHEC — Center for Recruitment &

Department of Vocational Rehabilitation

Retention

68.

USC School of Medicine

25.

Dial Page

69, 70. Companion Technologies, Inc.

26.

DuPont Pharmaceuticals

71.

Mosteller Design and Construction

27.

Wallace Laboratories

72.

Ciba-Geigy

28.

The Pain Therapy Centers

73.

Roper Hospital

29.

Physician Sales & Service, Inc.

74.

BFI Medical Waste Systems

30.

Ross Laboratories

75.

Raggio Associates, Inc.

31.

Smith Kline & French Laboratories

76, 77, 78. CompuSystems

214

The Journal of the South Carolina Medical Association

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION
VOLUME 85 MAY 1 989 NUMBER 5

THE NON-OPERATIVE CARE OF THE VASCULAR
SURGICAL PATIENT

GILBERT B. BRADHAM, M.D.*

The vascular surgeon is currently well trained
to operate on vascular surgical conditions. In past
years such training was an accelerating panorama
of new surgical feats with new prosthetic grafts,
new sutures, new instruments and new tech-
niques. Most of the current vascular operations are
now standardized with accepted operative indica-
tions, techniques which have proven themselves,
and technological adjuncts which have been well
tested. Vascular surgery, while young, has come
of sufficient age that most vascular surgeons agree
with each other, a condition unusual in the
professions.

During the maturation of vascular surgery per-
haps the most controversial subject has been the
decision not to operate. A frequent clinical argu-
ment has been “Let’s try a graft, if it works, good,
if it doesn’t, we can always amputate.” Another
has been “We are in the salvage business, let’s try
to salvage, even if we have to run a graft down to
his little toe.” Experience now provides a much
more objective probability of significantly help-
ing some patients and the futility of vascular
surgery to others.

This article is written as a guide of measures to
help the patient whose blood vessels are not ame-
nable to surgical alterations or bypass.

THE PROBLEMS

Most current arterial vascular problems stem

° Department of Surgery, Medical University of South Caro-
lina, 171 Ashley Avenue, Charleston, S. C. 29425-0950.

from atherosclerosis. Atherosclerosis is a condition
of lifestyle. Most venous problems are secondary
to recurrent venous thrombosis.

The most frequent problem of the patient with
vascular impairment is that of obstructive athe-
rosclerotic plaque providing lack of tissue perfu-
sion during muscular work. Intermittent claudi-
cation is a perfect example of this type of problem
but is fundamentally no different than angina
pectoris or mesenteric ischemia. Because of its
frequency we will use claudication as a clinical
example which often demands non-vascular sur-
gical care.

Patients with intermittent claudication have
symptoms of muscular pain during exercise. At
rest, blood flow to the calf muscles is in the range
of 2-5 ml. of blood per 100 grams of muscle per
minute. During exercise, even as mild as walking,
the blood flow may increase to 50 ml. blood per
100 grams muscle per minute. If the arteries are
diseased and cannot deliver blood flow sufficient
to provide oxygen for lactate metabolism, lactate
and hydrogen ions accumulate in the underserved
muscle and cause pain. The patient stops exercis-
ing, the demand for blood flow diminishes, and
there is cessation of pain.

When the above condition occurs frequently
enough, the patient seeks the advice of a physi-
cian. The symptoms alone are sufficient to denote
vascular insufficiency. After the physician has
surveyed all of the pertinent patient data he may
wish to have the patient evaluated in a vascular
diagnostic laboratory.

May 1989

221

THE VASCULAR SURGICAL PATIENT

Vascular diagnostic laboratories utilize a vari-
ety of technological methods of measuring vas-
cular disease and its effect on blood flow and
perfusion. When intermittent claudication is the
problem, measurement of blood pressure at the
thigh, calf, ankle, and toe levels is important.
While initially a screening test, these initial pres-
sures do give objective evidence of vascular im-
pairment, direct attention to the necessity of
angiography and serve as valuable data against
which to compare therapeutic modalities.

Next, the patient should have angiography.
There are constant improvements in the discipline
of vascular radiology. At present, with balloon
occlusion of the vessel to be studied and selective
injection of contrast media, vascular disease can
be radiographically well defined.

If the vascular disease and the patient’s general
condition indicate, re-vascularization of the leg is
the optimal choice. If, for any reason an operative
choice appears unwise, conservative management
is indicated. The remainder of this presentation
outlines some of the treatment which we have
advocated in many of the patients sent to us who
we consider better served by conservative man-
agement.

TOBACCO

Nicotine produces peripheral vasoconstriction.
In a previous article in The Journal of the South
Carolina Medical Association,1 we showed, by
thermographic pictures, the profound vasocon-
striction effect of nicotine. The value of ther-
mography in these patients was that when shown
the effect of one cigarette on their blood vessels,
many of the patients would literally throw their
cigarettes away. It is well considered that nicotine
contributes to the formation of vascular disease. It
is undeniable that a patient should cease smoking
when his vascular disease becomes symptomatic.
It is extremely advantageous to the patient to have
objective evidence that smoking is a part of his
vascular problem. Thermography is most useful
but is rarely available. If the physician can show
the patient that changes in blood pressure, heart
rate or skin temperature are affected by nicotine,
the cessation of smoking is greatly facilitated.2

NUTRITION

Atherosclerosis is a condition of inappropriate
lipid metabolism. In ethnic groups such as the
Vietnamese and the Mexican Indians where diet is

222

low in fat and lifestyle requires high energy ex-
penditure, atherosclerosis is minimal. In popula-
tions where omega-3 oils are used such as by
Eskimos and Mediterranean groups, atherosclero-
sis is minimized. The average American, however,
is raised on a diet inappropriately high in fat. We
surveyed our hospital employees in 1987 and
found that the average diet selected in our caf-
eteria had a fat content of over 50%. When con-
fronted with the average American atherosclerot-
ic, the physician must studiously outline a diet low
in fat and consonant with expected daily caloric
expenditures. We advise a diet certainly as low as
20% fat and hopefully approaching 10% fat. Pro-
tein should be tailored at 15% and the remainder
is carbohydrate. The carbohydrate portion of the
diet is optimally delivered with a variety of cere-
als, vegetables and fruits. The variety provides the
balance of vitamins and minerals necessary, and
the cereals, vegetables and fruits all provide
enough fiber for optimal intestinal function and
diminished cholesterol uptake. Minimization of
fat is the prime focus of diet alteration and the
patient must be educated to look for fat hidden in
breads, desserts and food preparation. Addi-
tionally, he should be instructed to look for the
types of lipids which benefit him and avoid those
which prove harmful. He should avoid saturated
fats. When oils are necessary, the best are soybean
and olive oils.

SKIN CARE

Most of the patients who have come to amputa-
tion due to vascular disease have trauma as a
culminating event. Often the traumatic event is
not immediately recognized, especially in the
neuropathic foot of the diabetic. Sometimes the
traumatic event probably would have healed had
the patient sought and received medical advice
including antibiotics and skin care. We advocate
that skin care of the feet and legs of the vascularly
impaired extremity be focused on cleanliness,
protection from excessive moisture or excessive
dryness, and protection from trauma. If there is
any tendency to minor abrasion, scratches, insect
bite or other minor trauma in the lifestyle of the
patient we recommend daily use of PhisoHex to
minimize surface bacteria. Daily bathing, fresh
clean socks and change of footwear if accidentally
wet are advisable. Intense emphasis should be
focused on thick cotton socks and excellent fit of
all shoes. Sir Paul Brand3 had special shoes built

The Journal of the South Carolina Medical Association

THE VASCULAR SURGICAL PATIENT

for the neuropathic feet of his leper patients, a
condition not basically unlike the neuropathic feet
of some diabetic patients.

EXERCISE

Moderate exercise is excellent therapy for the
vascularly impaired patient. With appropriate ex-
ercise the mitochondria of muscle cells increase in
number and there is increase in oxidation capac-
ity.4 With exercise, collateral blood supply in-
creases and capillary networks become more
profuse. The musculature of the heart increases in
volume and strength and the myocardial arteries
actually increase in size. There is even some evi-
dence to believe that the atherosclerotic plaque is
capable of diminution in size with appropriate
exercise.

Exercise is considered appropriate when it is of
the intensity to require a physiological response.
Thirty minutes of exercise three times per week at
an intensity to raise heart rate beyond 60% of
maximum is deemed an intensity level sufficient
to evoke beneficial physiological changes. Most
vascular patients cannot exercise at this intensity.
For them a good 30- to 60-minute walk on a daily
basis is an approach to benefit. The mere focus of
attention on exercise no matter how limited tends
to have psychological benefits and be a protector
against harmful stress.

POSITION

Position is more an important consideration in
venous than in arterial disease though it can be a
component of both. When venous insufficiency is
present in the lower extremities there can be little
benefit from sitting still. We advise our patients to
be walking or to be in a position with the legs
elevated. When sitting is mandatory at work or
while traveling, we advise the constant movement
of the legs and feet, and frequent standing and
walking. When traveling in an automobile our
patients are advised to stop on the roadside every
30 minutes and get out and walk for two to four
minutes. The patient with incompetent veins
should sleep with the legs elevated. This can be
accomplished with eight-inch blocks beneath the
foot of the bed or with the use of pillows or an
elevation of the bottom portion of the mattress.
The patient with arterial insufficiency should
sleep flat in bed. If he has rest pain, he will get up
and hang his feet downward. This symptom de-

notes an advanced and ominous stage of his
disease.

SHOES, SOCKS, STOCKINGS, AND
CLOTHING

The shoe is one of the most important consider-
ations for the patient who suffers from vascular
insufficiency. We advise a “comfortable” shoe
and examine it personally. The use of soft, well-
fitted athletic shoes is increasing in usage. Excel-
lent walking shoes can now be attained and are
generally well-designed to promote comfort, sup-
port and a minimum of trauma. Socks should be
comfortable and clean. Color has no importance.
Elastic stockings for the patient with venous insuf-
ficiency are excellent if they are individually fit-
ted, do not bind proximally and are used while
ambulating. There are no convincing data to indi-
cate that elastic stockings are of value to the
bedridden patient unless he is exercising his legs
while in bed. It is the contraction of the muscles
which pump blood back to the heart, not the
elasticity of the stocking. The stocking simply
provides a resistance for the muscle to work
against so as to provide a pumping action.

PROSTHESES

A prosthesis should be changed if it is ill-fitting.
The physician must constantly be aware of pres-
sure points caused by prostheses. These occur
frequently on the anterior bony surfaces of the leg
and are heralded in their early stages by rubor and
hyperpigmentation. Too frequently pain is absent
until a catastrophic breakdown of skin occurs.
Generally, commercial fitters of prostheses are
quite willing to modify their product to individual
requirements.

PAIN CONTROL

When vascular insufficiency progresses to the
point of producing pain at rest, a critical lower
limit of blood flow has been approached. At this
point the risks of revascularization must be re-
analyzed. If surgery is again judged infeasible,
analgesics, hypnotics and narcotics may be neces-
sitated. If such medications are insufficient for
pain control, then only amputation remains. If
amputation is resorted to, it should be performed
at a level judged to be of the potential to heal and
to be of permanent adequacy.

May 1989

223

THE VASCULAR SURGICAL PATIENT

STRESS

Each person responds differently to the stresses
of societal living. If stress is considered by the
physician to be a complicating factor of vascular
insufficiency, it must be dealt with as definitely as
smoking cessation. Stress, like nicotine, causes vas-
oconstriction presumably through the increased
production of epinephrine. Stress and fatty diets
are the sure combination of producing advanced
atherosclerosis. The treatment of stress is to de-
velop for the patient an appropriate change in
lifestyle. This may imply marital counseling,
change of job, cessation of political pursuits or
simply finding a diversion which produces peace
of mind. Stress may frequently be effectively
countered with simple returns to the basics of
living, farming, gardening, vacation, travel, etc.
Combined with appropriate diet and exercise an
active avoidance of stress can be meaningful to-
wards better health.

MEDICATIONS

We do not consider that medications are the
appropriate way to deal with atherosclerotic vas-
cular disease. In some instances, however, they
cannot be avoided. Aspirin in small doses is an
effective inhibitor of platelet aggregation. Hepa-
rin in the hands of an intelligent out-patient can
be used effectively to prevent thrombosis. Cou-
madin is certainly used extensively, is sometimes
well-indicated, but probably is over-used. Both
Heparin and Coumadin pose significant risks.
They should both be avoided in persons who by
their jobs or circumstances are at risk to trauma.

We have not seen remarkable benefit from
vasodilators in patients whose vessels are rigidly
atherosclerotic. We consider alcohol to be detri-
mental rather than beneficial. The drugs which
are designed to lower cholesterol are, except in
extreme cases, less effective than diet and ex-
ercise.

Medications, in short, do not materially affect
the atherosclerotic process.

WORK

Beyond marriage and family, work is the most
important factor of our lives. Enjoyable, produc-
tive work relieves more stress than it produces. It is
frequently seen that relatively good health is en-
joyed during our working years only to deterio-
rate upon retirement. In each vascular case we

224

elicit information about the patient’s job and its
relation to his symptoms. As examples, we have
seen the hunt and peck typist with Raynaud’s
Syndrome in the typing finger. The jack hammer
operator is another example of work-related vas-
ospastic disease. The loom operator in a mill may
show vascular compression of his subclavian ar-
teries as may the weight lifter.

The relationship of the job to the vascular im-
pairment is an individual search for information
and logical insight into their relationship. The two
are frequently related, sometimes as cause and
effect, at other times as treatment or even cure.

EDUCATION

The education of the patient and his family is
the most important aspect of conservative man-
agement. When a non-operative decision is made
there is the potential for the patient to become
depressed with hopelessness. It is at this moment
that his attention can be captured with knowledge
of himself and the feasibility of non-operative
alternatives. To achieve this state, it has been our
habit to acquaint the patient with pictures and
drawings of his vasculature, indication of how his
atherosclerotic lesion is disturbing flow (we refer
to it as “like rust in a pipe”) and specifically why
an operation is not a wise choice. The patient
should be taught how nicotine constricts blood
vessels, compounding his ischemia and risking loss
of limb. We show him his vascular studies and his
angiograms to reinforce the credibility between
doctor and patient. The patient should be well
instructed in the principles of nutrition and given
written material to guide him and his spouse in the
selection and preparation of food. Exercise educa-
tion is important including the alternatives to
exercises which are difficult or impossible for
him. We advocate bike riding or swimming for
those who cannot walk well. Entirely different
sets of muscles are used and oftentimes the moti-
vated patient gains confidence and renewed ca-
pacity doing exercises he did not believe he was
capable of. Finally, we try to educate the patient
in the natural history of his disease condition,
leaving a window of hope that by lifestyle change
and dedication to health he can, in fact, become
healthier.

SUMMARY

It is as important to recognize that some pa-
tients will not improve by operative surgery for

The Journal of the South Carolina Medical Association

THE VASCULAR SURGICAL PATIENT

vascular disease. When a decision is made for non-
operative management, responsibility dictates
that the patient be given a regimen of measures
designed for stabilization of his present condition
and reversal of lifestyle trends which caused it.
These include cessation of smoking, appropriate
exercise and nutrition, excellent skin care, atten-
tion to clothing and shoes, management of pros-
theses, control of pain, and control of stress. A
careful analysis of the patient’s medications and
his work environment must be made and tailored
to his needs. Finally, the patient should be stu-
diously educated as to his disease process and its
relationship to his lifestyle. Only through under-

standing of the reasons for taking good care of
himself can patients be effective in following their
physician’s advice. □

REFERENCES

1. John E. Parker, M.D. and Gilbert B. Bradham, M.D.; Ther-
mographic Demonstration of Nicotine-Induced Vas-
oconstriction, The Journal of the South Carolina Medical
Association, 65:423-425, December. 1969.

2. Joan Barry; Kimberely Mead; ElizaUdr G. Nabel, M.D.;
Michael B. Rocco, M.D.; Stephen Campbell, MB; Terrence
Fenton, EdD; G. H. Mudge, Jr., M.D.; Andrew P. Selwyn,
M.D.; Effect of Smoking on the Activity of Ischemic Heart
Disease, JAMA, 261:398-402, January 20, 1989.

3. Paul Brand (Personal Communications).

4. McArdle and Katch, Exercise Physiology, Second Edition,
Lea A Febiger, Philadelphia, PA, 1986.

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May 1989

225

UTILITY OF LESSER SAPHENOUS VEIN
AS A SUBSTITUTE CONDUIT*

ARTHUR GRIMBALL, M.D.**

R. RANDOLPH BRADHAM, M.D.
P. REID LOCKLAIR, JR., M.D.

Occasionally patients present for both cardiac
and peripheral vascular procedures in whom stan-
dard graft conduits are inadequate. Lesser saphe-
nous vein may provide an alternate conduit of
great utility in these cases. We report two such
cases including brief information regarding the
lesser saphenous vein an its harvesting.

Many thousands of vascular bypass procedures
are performed annually in the United States. Be-
cause of the ready availability and/or superior
patency rates, conduits of choice have become
reversed or insitu greater saphenous vein, internal
mammary artery, and prosthetic grafts. Inevita-
bly, patients will present in whom such conduits
are inadequate, unsuitable or unavailable. In such
cases, the lesser saphenous vein should be remem-
bered as a very satisfactory alternative conduit.
We present examples of its utility for both cardiac
and peripheral vascular cases, as well as tips re-
garding its anatomy and harvesting.

Case 1: An 81-year-old white female presented
with severe exertional angina. Cardiac catheter-
ization demonstrated normal ventricular function
and severe three-vessel coronary artery occlusive
disease. She was felt to need coronary artery by-
pass grafts to the right posterior descending, ob-
tuse marginal, left anterior descending, and
diagonal coronary arteries. She was known to have
undergone bilateral complete greater saphenous
vein stripping for varicosities some 30 years ear-
lier. Assessment of her arm veins found them to be
diminutive and unsuitable as graft conduits. Use
of bilateral internal mammary arterial grafts
would be inadequate for complete revasculariza-
tion. The lesser saphenous systems were assessed
by non-invasive means and found in the infra-
popliteal area. They could not be traced to the

° From the Department of Surgery, Roper Hospital, Charles-
ton, S. C.

0 ° Address correspondence to Dr. Grimball at 315 Calhoun

Street, Suite 405, Charleston, S. C. 29401-1102.

226

ankle. Nevertheless, it was decided to explore
these veins.

She was taken to the operating room, and after
the induction of general endotracheal anesthesia,
she was placed in the prone position. The lesser
saphenous veins were identified in each leg, and
dissected out from the ankle to the popliteal fossa.
These veins had a gross appearance similar to
greater saphenous vein, and were felt to be quite
adequate for use as graft conduits. Following
closure of the leg wounds, she was replaced in the
supine position and underwent uneventful coro-
nary bypass grafting to the left anterior descend-
ing, diagonal, posterior descending, and obtuse
marginal coronary arteries. Her postoperative
course was unremarkable. The leg wounds healed
nicely, and there was essentially no pedal edema
noted despite absence of both saphenous veins
bilaterally.

Case 2: A 67-year-old-man presented with se-
vere left leg claudication and a non-healing ulcer
on the pad of the left third toe. Angiography
demonstrated occlusion of the left superficial
femoral artery with reconstitution at the level of
the distal popliteal artery. The anatomy man-
dated a femoral-to-infrageniculate popliteal ar-
tery bypass. His past history was remarkable for
coronary bypass graft times two with use of left
greater saphenous vein. He also had undergone a
right femoral-popliteal bypass utilizing right
greater saphenous vein from the groin to the calf.

In order to achieve optimal graft patency, it
was preferred to avoid crossing the knee joint with
a prosthetic graft. At operation, a sufficient length
of autologous vein graft was obtained by har-
vesting the distal remnant of the right greater
saphenous vein, as well as the entire left lesser
saphenous vein. When used together, these easily
reached from the left common femoral artery to
the left infrageniculate popliteal artery. Post-
operatively, moderate pedal edema was noted on

The Journal of the South Carolina Medical Association

USE OF LESSER SAPHENOUS VEIN

the left, but the wounds healed well, and arterial
revascularization has been quite satisfactory with
healing of the ulcer on the left third toe.

DISCUSSION

Although the lesser saphenous vein is not our
first choice as arterial graft conduit, we have
found it to be very useful in cases in which other
conduits are unavailable, inadequate, or unsuit-
able. The quality and caliber of this vein is com-
parable to the distal half of the greater saphenous
vein. By contrast, arm veins are of poor quality,
and the patency rate of arm veins for use in
coronary surgery is questionable. 1 While patency
rates for lesser saphenous vein when used as coro-
nary grafts have not been studied, they have been
studied when used for lower extremity revascula-
rization. Under these circumstances, the lesser
saphenous vein appears to be comparable to
greater saphenous vein in terms of patency.2

The lesser saphenous vein is fairly constant in
anatomical position. It originates just posterior to
the lateral malleolus and courses cephalad be-
tween the heads of the gastrocnemius muscle. It
lies in a subcutaneous position from the ankle to
the popliteal fossa. It pierces the deep fascial layer
to enter the popliteal fossa, where it communi-
cates with the popliteal vein. Careful dissection of
the vein in the popliteal fossa can provide a sur-
prising amount of additional length to the har-
vested conduit. The sural nerve parallels the lesser
saphenous vein in the lower half of the leg and
provides an additional landmark for its identifi-
cation.

It is relatively easy to harvest the lesser saphe-
nous vein using one of three approaches. Case 1

illustrates the most direct approach. The patient is
placed prone, and the vein is identified with the
sural nerve just posterior to the lateral malleolus. It
is then dissected proximally to the popliteal fossa.
More commonly, the vein is dissected out with the
patient in the supine position. When this is under-
taken, it is easiest to flex the hip 45 degrees and the
knee 90 degrees, then internally rotate the hip.
This exposes the lateral aspect of the leg, and the
vein is again harvested from the ankle to the knee
with the surgeon on the ipsilateral side as the vein
is being harvested. Exposure is only slightly diffi-
cult in the popliteal fossa. When the surgeon
works from the contralateral side, an assistant
provides flexion of the hip and knee, and external
rotation of the hip. In this circumstance, exposure
is better in the popliteal fossa, but more difficult in
the lower leg.

SUMMARY

The lesser saphenous vein provides a useful
alternative graft conduit for both cardiac and
peripheral vascular procedures. Its gross ap-
pearance and handling characteristics are similar
to greater saphenous vein, and its patency rates
appear comparable. It is harvested with minimal
difficulty. Harvesting is well tolerated, even in the
absence of the greater saphenous system. Its use
should be strongly considered when standard con-
duits are inadequate or unavailable. □

REFERENCES

1. Stoney WS, Alford WC Jr, Burrus GR, et al: The fate of arm
veins used for aorta-coronary bypass grafts. J Thorac Car-
diovasc Surg 88 (4): 522, 1984.

2. Weaver FA, Barlow CR. Edwards WH. et al: The lesser
saphenous vein: Autogenous tissue for lower extremity re-
vascularization. J Vase Surg 5 (5): 687, 1987.

May 1989

227

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228

The Journal of the South Carolina Medical Association

NEWSLETTER

Mav 1989

ANNUAL MEETING HIGHLIGHTS

SCMA President. 1989-1990

Daniel W. Brake, MD, was installed as the 126th President of the
SCMA during the Annual Meeting in Charleston. At the Inaugural
Banquet on Saturday, April 30, Dr. Brake, a Charleston family
physician, stressed the importance of physicians becoming
involved in organized medicine in an effort to stem the trend
toward socialized medicine in this country.

Elections

Results of the elections held during the Annual Meeting were as
follows:

President-Elect :
Secretary:
Treasurer:
Trustees:

AMA Delegate:
AMA Alternate:

John W. Simmons, MD, Spartanburg
Bartolo M. Barone, MD, Charleston
John W. Rheney, Jr., MD, Orangeburg
District 1: J. Chris Hawk, III, MD,

Charleston, and John B. Johnston, MD,
Walterboro

District 3 : Richard M. Carter, MD,

Greenwood
District 5:

District 7 :
Sumter
District 8:
Orangeburg
District 9:

Roger Gaddy, MD, Winnsboro
J. Capers Hiott, MD,

Dallas Lovelace, MD,

Carol S. Nichols, MD,

Spartanburg

Donald G. Kilgore, Jr. , MD, Greenville
J. Gavin Appleby, MD, Columbia

Auxiliary News

Mrs. William L. (Robin) Meehan was installed as President of the
SCMA Auxiliary for 1989-1990. See the Auxiliary Page in this
month's Journal for Mrs. Meehan's acceptance speech.

House Actions

During the closing session of the House of Delegates, the
following resolutions were adopted:

A SC Chapter of the American Academy of Pediatrics
resolution to urge all Legislators, school board members,
educators, parents and other adults within SC to seek
alternatives to corporal punishment within the educational
system.

A Board of Trustees resolution to urge hospital medical
staffs to work with their administrators and governing bodies in
developing "smoke-free" hospitals and to urge all physicians to
implement a no smoking policy in their office or other place of
work, as well as a Lexington Medical Association resolution to
strongly endorse the passage of the Clean Indoor Air and
Promotion of Public Health Act of 1989 and to provide penalties
and violations.

A Medical Aspects of Sports Committee resolution to reaffirm
the SCMA position that the use of any substance taken in abnormal
quantity or taken by an abnormal route of entry into the body
~**with the purpose of increasing an artificial and unfair advantage
is contrary to the ethical principle of athletic competition, and
that the eradication of the usage of anabolic-androgenic steroids
is in the best interest of sports.

A boating safety resolution supporting mandatory boater
education was referred to the Board of Trustees for further
consideration .

Awards

Walter Bonner, MD, received the Thomas E. and Shirley A. Roe
Award for the best article by a practicing physician published in
The Journal during 1987-1988. The article, titled "Yellow Fever
at Mt. Pleasant, Charleston Harbor, S. C. , in 1857, With a Review
of its Consequences," was the first historical paper to win the
award.

William F. Mahon, SCMA Executive Vice President, was presented
the President's Award by outgoing President, Thomas C. Rowland,
Jr., MD.

Susanne G. Black, MD, Dillon, received the A. H. Robins'
Physician's Award for Community Service.

The South Carolina Political Action Committee (SOCPAC) was
recognized by the American Medical Political Action Committee
(AMPAC) as the outstanding state medical political action
organization in the US. SOCPAC was recognized also with a first
place AMPAC award in the "Contributions Per Member" category.

More than $3 0,000 was raised during the past year by the SCMA
Auxiliary to support medical education and research in SC. MUSC
received a check for $23,124.00 and the USC School of Medicine
was given $9,882.00 in ceremonies during the opening session of
the SCMA House of Delegates on April 27.

The SCMA Auxiliary and the SC Institute for Medical Education and
Research (SCIMER) presented joint scholarships based on need and
merit to worthy students at both of the state's medical schools.
Students from MUSC receiving scholarships were Scott Corley,
Spartanburg? Timothy Jones, Summerville; Peter Neidenbach,
Gainesville, Georgia? Jamie Rentz, Spartanburg; and Wade Strong,
Marion. USC School of Medicine students who received
scholarships were Dave Amaker, Swansea? Judson Gash, Charleston;
David Hunt, Greer? Heather Gallman, Florence? and Trey Chandler,
Bishopville.

Joseph T. Watson, a rising senior at MUSC, received the Stuckey
scholarship, presented annually to a medical student from Bamberg
County .

Awards to the media for exceptional reporting on medically
related topics were presented to Lexie Chatham, SC Educational
Radio; Sharon Spears, WRDW-TV? and Jeff Owens, the Sumter Item .

O'Neill Barrett, Jr., MD, Chairman of the SCMA CME Committee, was
given a special award for his contributions to quality continuing
medical education in the state.

HIGHLIGHTS OF BOARD OF TRUSTEES MEETING ON APRIL 26

The board reviewed correspondence from US Representative Butler
Derrick who has introduced a bill, HR 1811, which proposes to
eliminate MAAC limits, the medically unnecessary provisions which
result in P.A.B. letters, and the notification requirement for
unassigned claims for elective surgery when the patient is
expected to incur more than $500 in out-of-pocket expenses. The
SCMA board will write Congressman Derrick expressing appreciation
for this proposed legislation.

Reports on the activities of the SCMA's Resident, Student and
Young Physicians' Section were received as information

Special guests to the meeting included: Tommy Walters, Medicare
Ombudsman; Bambi Sumpter, EdD and Katy Wynne, EdD, the SC
Department of Education's health educators who travel with the

Health Education Van which the SCMA, SCIMER and the Auxiliary
donated; representatives of the JUA; and Charles Riddick, Blake
Williams and Keith Waters, MD, of Carolina Medical Review.

In response to AMA interest, the board agreed to encourage
discussion among the PRO, medical licensure board, the two
medical schools and SCMA's CME Committee regarding the need to
provide focused CME programs for enhanced clinical competence.

Following much review and discussion, the board voted to request
deletion of physicians from proposed SC House Bill 3599.
Although this bill appeared initially to offer a patient
privilege for confidences told to a physician when being treated
for an emotional or mental condition, further study indicated
that the bill would not be beneficial. Information on how to
obtain such protection under current law will be published in the
upcoming issue of the Physicians' Risk Management Bulletin.

MEDICARE UPDATE

Referring Physician ID Number

The SCMA has been informed that, effective June 1, Medicare will
require inclusion of the referring physician's Medicare
Identification number on all claims for which a consulting code
is used. Referring MDs are encouraged to provide their SSN to
the consulting physician. Suggested mechanisms would be a
referral card or superbill that could accompany the patient. If
your Social Security number is on your prescription pad, this
would be another means of transmitting the number to the
consulting physician. We have evaluated statewide mechanisms,
such as publication of a directory, and have found this would be
an illegal usage of the Social Security number.

Further information will be provided in a BC/BS Medicare
Advisory.

The Physician Payment Review Commission Report to Congress

The Physician Payment Review Commission (PPRC) was created in
1986 to advise Congress on reform of the methods used by Medicare
to pay physicians. The PPRC, in its proposals submitted to
Congress in late April, recommends that Congress enact
legislation this year that would replace Medicare's current
"customary, prevailing and reasonable" method of paying
physicians with a fee schedule based primarily on resource costs.
The fee schedule consists of a relative value scale (RVS) , a
conversion factor and a geographic multiplier.

The Commission recommends that the RVS comprise two cost
elements: relative physician work and practice costs. Coding

changes will be necessary in the important areas of surgical
global fees and evaluation and management services, with time

incorporated into the definitions for visit codes. The

Commission's formula for incorporating practice costs in the RVS
allows for overhead to be calculated independently of physician
work. Under this formula, changes in fees resulting from
adoption of a fee schedule are estimated at about half as great
as the preliminary estimates reported by Dr. Hsiao last year.
Refined estimates of practice costs by specialty will be used
initially in the RVS, but will be superceded later by estimates
of practice costs by category of service. Further, the

Commission recommends that premiums for professional liability
insurance be treated as a separate factor in calculating practice
costs.

The conversion factor proposed would transform the RVS into a
schedule of dollar payments for each service. The geographic
multiplier would reflect only variation in overhead costs of
practice, and specialty differentials — differences in payment
of physicians of different specialties for the same procedure
code — would be eliminated under the fee schedule.

The PPRC is not recommending mandatory assignment but proposes
the following policies to increase protection for beneficiaries:
limiting charges for unassigned claims to a fixed percentage of
the fee schedule amount? eliminating balance billing for
qualified Medicare beneficiaries; and continuing the
participating provider program and its payment differential which
provides higher fees to participating physicians.

The PPRC recommends a transition that would adjust payments in
the direction of the Medicare Fee Schedule to give physicians and
beneficiaries time to adjust, allow for midcourse corrections and
increase the chances that private payers will implement similar
changes .

In attempting to reduce inappropriate and unnecessary services to
contain costs while not sacrificing access and quality of care,
the PPRC recommends three approaches:

(1) Giving physicians collective incentives to contain costs

through expenditure targets. The expenditure target for
physicians' services under Part B would be used to determine

annual conversion factor updates under the fee schedule and would
reflect increases in practice costs, growth in the number of
enrollees and a decision concerning the appropriate rate of
increase in volume of services per enrollee. Whether the update
would be higher or lower than the increase in practice costs
would depend on differences between actual and targeted

expenditures.

(2) Increasing research on effectiveness of care and

expanding the development and dissemination of practice

guidelines.

(3) Improving utilization management by carriers and peer
review organizations.

Participating Physicians

A flyer has been developed by the SCMA for display in your office
regarding the benefits you provide your Medicare patients by your
participation in the Medicare program. For a sample copy, please
call Kim Fox at the SCMA office (798-6207 or 1-800-327-1021) .

Non-Participating Physicians

A word of appreciation to the 941 physicians who have signed up
for the SCMA's Personal Care program. For additional brochures
or to obtain information, call Kim Fox at SCMA headquarters.

Medicare Advisory and Special Notice

A Medicare Advisory and a special notice regarding ICD-9-CM codes
was recently mailed by BC/BS of SC. Be sure to review this
important material.

SCREENING FOR NURSING HOME ADMISSIONS

Federal law has mandated that the state of South Carolina screen
patients who are applying for nursing home admission to identify
those with major psychiatric disease, mental retardation, or
developmental ly disabled without mental retardation. The object
of this law is to assure these patients receive active treatment
for their psychiatric or mental retardation condition.

The Community Long Term Care service managers will be screening
all applicants. Those applicants who are positive for mental
illness or developmentally disabled without mental retardation by
the initial screen must be further examined by CLTC to determine
the extent of their illness. Patients with mental retardation
will be referred to the Department of Mental Retardation for
examination.

An examination format and form for mental illness and
developmental disability will be referred to the attending
physician of the nursing home applicants. You should look
closely at the instructions that accompany these forms and
complete the forms as expeditiously as possible. Any undue delay
in returning these forms will also delay final consideration of
the applicant for nursing home placement.

A fee will be paid by the Finance Commission for this examination
and the completion of the form. Medicaid patients will be billed
in the usual manner on a HCFA form 1500 and a special form will
accompany the patient on non-Medicaid patients. The fee
established for this examination is $75.00.

HHSFC encourages your cooperation so that this process can be

implemented smoothly. If you have any questions, please call J.
Gavin Appleby, MD, (803) 253-6100.

MEDICAID UPDATE

Improved Access to Long Term Care Services

Responding to legislative concerns regarding limited access to
needed long-term care services for Medicaid recipients, HHSFC , in
mid-April, approved a package of actions, including the
following, of interest to physicians:

- coverage will be extended to ICF patients in hospital
swing beds - the swing bed rate will be based on the average
hospital-based nursing home rate (upon approval by HCFA) .

- administrative days will be covered for patients meeting
SNF or ICF criteria, as long as such care is not available in a
nursing home.

Less Than Effective Drugs (DESI) List

The State Health & Human Service Finance Commission has recently
issued its new DESI list which supercedes the Medicaid bulletin
dated August 4, 1986. The list contains those products currently
marketed (or have had their approval withdrawn) and also
evaluated as less than effective by the FDA. Such drugs are not
reimbursable by Medicaid. To obtain a copy of the list or if you
have questions, call your provider representatives at (803) 253-
6179.

CERTIFICATION OF PHYSICIAN OFFICE LABS

Although OBRA-1987 stipulated that all labs which have a volume
of tests in excess of 5,000 per year would have to meet all of
the certification requirements of independent clinical labs
effective January 1, 1990, subsequent passage of the Clinical
Laboratory Amendments of 1988 established a July 1, 1991
implementation date of more reasonable standards.

At this time, it appears that the lab requirement of OBRA-87 will
be repealed and hence the deadline for standards for physician
office labs will be July 1, 1991.

Additional information will be provided as it becomes available.

AIDS UPDATE

The Social Security Administration has issued a detailed outline
discussion of the Social Security and Supplemental Security
Income disability programs and procedures, with special emphasis
on AIDS cases. For a copy of this outline, contact Melanie

McLendon or Kim Fox at SCMA headquarters.

HANDICAPPED LICENSE PLATES

Physicians should be aware that, according to SC law, disabled
license ID tags are authorized for only those persons (a)
disabled by an impairment in the use of one or more limbs and
required to use a wheelchair or (b) disabled by an impairment in
mobility, but otherwise qualified for a driver's license as
determined by the Highway Department. Handicapped Certificates
signed by physicians on each license application form should
indicate the permanency of limb impairment or the
severity/permanency of mobility impairment.

PUBLICATIONS AVAILABLE

Available from the AMA are the following recent publications:
Medicare Carrier Review: What Every Physician Should Know About
"Medically Unnecessary" Denials (Cost: $12.50) and Physician
Guide to Home Health Care (Free of charge to AMA members; $15.00
for non-members) . For credit care orders call 1-800-621-8335, or
write AMA, 535 N. Dearborn St., Chicago, IL 60610.

The South Carolina Physician's Handbook on Child Abuse and
Neglect, by Otis L. Baughman, MD, and Martha G. Priest, MEd, can
be obtained from Ms. Priest, AHEC Coordinator, Spartanburg
Regional Medical Center, Spartanburg 29303.

SCMA NEWSLETTER
is a publication of the
South Carolina Medical Association.
Contributions welcomed.
Melanie McLendon, Editor
798-6207, in Columbia
1-800-327-1021, outside Columbia

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TAKAYASU'S ARTERITIS

JOHN T. TOLHURST, M.D.*

GRADY H. HENDRIX, M.D.**

Takayasu’s arteritis is a chronic inflammatory
arteritis of unknown etiology, which affects pri-
marily the aorta and its main branches, and occa-
sionally the pulmonary arteries. There are isolated
reports of involvement of the coronary arteries,1
and hypotensive retinopathy has also been re-
ported.2 The arteritis may be divided into two
phases: (a) an inflammatory phase which even-
tually leads to stenosis of the large vessels, but can
lead to aneurysm formation, and (b) an ischemic
phase, resulting from stenosis and secondary hy-
poperfusion of organs.3 Successful treatment of
this disease with steroids and cytotoxic agents,
when necessary, depends upon early recognition
in the inflammatory phase to avoid the serious
consequences of stenosis, leading to the ischemic
phase.

In a study of radiographic and angiographic
findings in 59 patients, 68% had abnormal chest x-
rays, and stenosis of the thoracic or abdominal
aorta was seen in 71%. 4 In 21 of these cases,
pulmonary arteriography was performed, and
86% (18) of those patients had abnormal occlu-
sion, stenosis, or dilatation. There was no correla-
tion between systemic arteritis and the extent of
pulmonary involvement. Calcification of the
aorta in Takayasu’s arteritis is present in the aortic
arch and descending aorta, in contrast to syphilitic
aortitis, which usually exhibits calcification of the
ascending aorta.

Takayasu’s arteritis most often affects children
and young women between the ages of 10 and 30,
although at least one study demonstrated the
mean age at diagnosis to be much older than this.5
Due to the fact that Takayasu’s arteritis often
presents with generalized symptoms of fever,
malaise, anorexia, weight loss, arthralgias and my-
algias, the interval to definitive diagnosis is often
extended.6 In a study of 32 North American pa-
tients, both non-vascular symptoms (arthralgias in

° Address correspondence to Dr. Tolhurst at: Family Medi-
cine Center, Spartanburg Regional Medical Center, 101 E.
Wood Street, Spartanburg, S. C. 29303.

Department of Medicine, Medical University of South Car-
olina, Charleston, S. C. 29425.

234

56%, fever in 44%, weight loss in 38%) and vas-
cular symptoms (arm claudication 47% and hy-
pertension due to renal artery stenosis 41%) were
seen. All patients had either multiple vascular
bruits 94% or absent pulses.7, 8 Occasionally, neu-
rologic symptoms such as dizziness, headaches,
syncope, diplopia, amarosis fugax and paresis may
be seen with vascular obstruction of the carotids
leading to cerebral hypoperfusion.

CASE REPORT

The patient is a 45-year-old white female, ini-
tially diagnosed with Takayasu’s arteritis in 1967.
She presented post partum with a syndrome of
severe headaches and hypertension with acute
pulmonary edema. Cardiac catheterization at
that time revealed severe coarctation of the prox-
imal descending aorta to the intrarenal portion of
the aorta. She underwent successful aortic bypass
surgery shortly thereafter, and did quite well for
the next eight years without the use of steroids or
cytotoxic agents.

She was seen for routine followup at MUSC in
1975, and due to symptoms of decreased exercise
tolerance and widened mediastinum on chest x-
ray, she underwent cardiac catheterization, which
revealed aortic regurgitation, dilatation of the
proximal ascending aorta, narrowing at the origin
of the left carotid, and total occlusion of the left
subclavian artery. The aortic graft was com-
pletely patent.

Echocardiogram in December of 1979 revealed
mild left ventricular hypertrophy, mitral insuffi-
ciency, and a normal aortic valve. Subsequently,
she was seen for routine follow-up at MUSC in
January of 1982 with EKG changes consistent
with extreme left ventricular hypertrophy. Echo-
cardiogram at that time demonstrated a very
thick septum and thick left ventricle mass, with
systolic anterior motion of the anterior leaflet of
the mitral valve and aortic regurgitation.

In April of 1982, she was referred back to
MUSC with complaints of fatigue, left and right
arm weakness, and right arm numbness, and was
electively admitted for cardiac catheterization

The Journal of the South Carolina Medical Association

TAKAYASU’S ARTERITIS

which the consulting cardiologist felt demon-
strated little change since her 1975 catheteriza-
tion. Due to the fact that her Westergren
sedimentation rate had risen to 106 mm/hr, rheu-
matology was consulted, and they felt a trial of
oral prednisone therapy was indicated. She was
started on 40 mg of prednisone q am on 4/10/82,
and this was continued for six weeks. The patient
had an excellent response to steroid therapy as
monitored both by symptomatic relief, a return of
her upper extremity pulses, and a marked de-
crease in her sedimentation rate by 5/28/82 to 38
mm/hr. By that time, she had been tapered to
prednisone dosage of 10 mg qod. She continued to
do remarkably well over the next six years and was
continued on prednisone the entire time due to
persistent elevation of her sedimentation rate. She
had several episodes of supraventricular tachycar-
dia controlled by verapamil, and developed inter-
mittent claudication of the upper extremities.

She was last seen in the Cardiac Clinic at SRMC
in September of 1988 with complaints of lum-
bosacral and thoracic spine pain. Subsequent lum-
bosacral and thoracic spine films demonstrated no
evidence of osteoporosis, and ultrasound of the
abdomen demonstrated no evidence of aortic
aneurysm.

DISCUSSION

Takayasu’s disease remains a poorly understood
entity from the etiologic standpoint. Many re-
searchers feel it is almost certainly auto-immune
in origin, although others feel the evidence is
inconclusive.9 There have been various reports of
association with tuberculosis, ulcerative colitis,
glomerulonephritis, Chron’s disease, and Still’s
disease.' The diagnosis of Takayasu’s disease
should be entertained in any patient with radi-
ographic abnormalities on chest x-ray, such as
calcification or irregular contour of the aorta (es-
pecially in premenopausal females). Symptoms of
paresthesias, arthritis, and arthralgias of the upper
extremities, especially of acute onset, and physical
findings of diminished or absent pulses of the
upper extremities or vascular bruits, particularly
in the neck area, should make one highly sus-
picious. Laboratory findings of unexplained ele-
vations in the sedimentation rate and mild anemia
are frequently seen. Once the diagnosis has been
made, based upon arteriographic evidence and/
or biopsy, management consists of early ag-

gressive steroid therapy,10 since both severity and
duration of the inflammation may affect the de-
gree of vessel involvement. Steroids must be used
cautiously in the hypertensive patient, as fluid
retention may induce severe hypertension. As re-
ported in an NIH study, patients who do not
respond to steroids at a dose of 1 mg per kg of body
weight will sometimes benefit from cytotoxic
agents such as cyclophosphamide.3

Surgical treatment, in the form of various by-
pass grafting procedures, is highly beneficial to
most patients. In a French study of 39 patients,
with a mean age of 33 years, 33 had operative
intervention with only one operative death, which
occurred two months after operation due to graft
infection.11 Of 21 hypertensive patients in this
study, 11 (52%) were totally cured (normotensive
without medications) and nine (42%) had signifi-
cant reduction in severity, with the one remaining
being the patient who died of infection. Fourteen
of these 33 patients had operations on brachio-
cephalic lesions, and 27 of those 29 grafts (93%)
remained patent. Twelve of those patients had
reduction of their symptoms, but two continued to
have upper extremity claudication. Surgical cor-
rection of pulmonary artery stenosis has been
successfully performed in at least two patients.12

The long term prognosis of Takayasu’s is diffi-
cult to assess due to the wide variance in severity,
associated disease states, and complicating factors
such as hypertension, smoking and hypercholes-
terolemia. In the North American study of 32
patients, only two of 32 died (median follow-up
five years), one of aortic aneurysm rupture and
one of pneumonia.8 In the Swedish study of 15
patients, six of the 15 died in the eight-year study
period, but four of these were smokers and three
also had hypercholesterolemia.5 In the French
study, four of 33 (13%) of the patients died within
two years. Clearly, early recognition of Tak-
ayasu’s disease and early intervention, both medi-
cally and surgically, will affect the future prog-
nosis for patients with this disease.

As illustrated by this case, long-term survival is
possible, even with severe disease. Unfortunately
for this patient, she has a very restricted lifestyle
due to her cardiac status and upper extremity
claudication. However the prognosis is not always
discouraging. In the North American study of 32
patients, 27 were functionally assessed at five
years. Twenty were working full time with mini-
mal disability and seven had significant func-

May 1989

235

TAKAYASU’S ARTERITIS

tional impairment. Again this emphasizes the
need for early recognition and treatment of Ta-
kayasu’s disease in the inflammatory phase, with
the objective of preventing, or at least delaying,
the ischemic phase. □

REFERENCES

1. Rose, A. et al. Takayasu’s Arteritis — A study of 16 Autopsy
Cases. Archives of Pathology and Laboratory Medicine
1980 May: 104(1): 231-237.

2. Ishikawa K. Survival and Morbidity After Diagnosis of
Occlusive Thromboaortopathy (Takayasu’s Disease). The
American Journal of Cardiology 1981 May; 47: 1026-1033.

3. Shelhamer, J. et al. Takayasu’s Arteritis and its Therapy.
Annals of Internal Medicine 1985 July; 103: 121-126.

4. Yamoto M. et al. Takayasu’s Arteritis: Radiographic and
Angiographic Findings in 59 Patients. Radiology 1986
Nov; 161(2): 329-334.

5. Waern, A. et al. Takayasu’s Arteritis: A Hospital Based
Study on Occurrence, Treatment, and Prognosis: An-
giology 1983 May; 34(5): 311-320.

6. Sketchier, J. Takayasu’s Arteritis Diagnosed in a Patient
with Long Standing Arthralgias and Arthritis: Southern
Medical Journal 1987 Apr; 80(4): 516-517.

7. Syed, Al-Awami et al. Takayasu’s Arteritis of the Upper
Extremities, a Case Report and Review of the Literature.
Angiology 1984 June; 35(6): 383-388.

8. Hall, S. et al. Takayasu’s Arteritis, a Study of 32 North
American Patients. Medicine 1985; 64(2): 89-99.

9. Nakao K. et al. Takayasu’s Arteritis: Clinical Report of
Eighty-four Cases and Immunological Studies of Seven
Cases. Circulation 1967 Jul; 35: 1141-1155.

10. Kaichiro I. et al. Regression of Carotid Stenoses after
Corticosteroid Therapy in Occlusive Thromboaortopathy
(Takayasu’s Disease): Stroke 1987 May-June; 18(3):
677-679.

11. Lagneau, P. et al. Surgical Treatment of Takayasu’s Dis-
ease. Annals of Surgery 1986 Feb; 205(2): 157-166.

12. Chauvaud, S. et al. Takayasu’s Arteritis with Bilateral
Pulmonary Artery Stenosis — Successful Surgical Correc-
tion. Journal of Thoracic and Cardiovascular Surgery 1987
Aug; 94(2): 246-250.

Alia ua^u

MEDICINE,

PHYSICIANS
AND
FLIGHT.

MAJOR CHUCK HELVEY
919-850-9549
Station-To-Station Collect

236

The Journal of the South Carolina Medical Association

PHYSICIAN MANPOWER AND
GRADUATE MEDICAL EDUCATION:
A REVIEW WITH IMPLICATIONS FOR
STATE POLICY DEVELOPMENT

JULIE JOHNSON McGOWAN*

G. DEAN CLEGHORN, Ed.D.**

In 1987, the Congress of the United States cre-
ated the Council on Graduate Medical Education
to address a number of issues concerning the
future health of the country’s population and to
formulate public policy regarding those issues.
The areas analyzed included the relationship be-
tween graduate medical education and quality
health care, potential funding sources for such
education, the underrepresentation of minorities,
and the impact of foreign medical graduates on
graduate medical education. The issue that gener-
ated the greatest controversy and seemed to per-
vade all others was the question of adequate
physician supply for demand. The question has
repeated itself throughout the history of this coun-
try and is now being addressed in South Carolina.

THE SUPPLY VERSUS
DEMAND PENDULUM

In the Jacksonian era of the 1830s when de-
regulation was the byword, medical schools pro-
liferated from four to over 80 by 1876. 1 In this
climate of deregulation, professional health care
organizations were born of a need for self-regula-
tion, and with the founding of the American
Medical Association (AMA) in 1847 and the Asso-
ciation of American Medical Colleges (AAMC) in
1876, physicians found themselves as active par-
ticipants in the formulation of governmental pol-
icy.2 In 1910, under the auspices of the AMA’s
Council on Medical Education and with the help
of the Carnegie Foundation for the Advancement
of Teaching, Abraham Flexner published his

° Address correspondence to Ms. McGowan at: Library, Uni-
versity of South Carolina School of Medicine, Columbia,
S. C. 29208.

Executive Director, South Carolina Area Health Education
Consortium (AHEC), and Associate Professor, Department
of Psychiatry and Behavioral Science, Medical University
of South Carolina, Charleston, S. C.

landmark study on medical education,3 which
resulted in a swing of the pendulum and the
closing of many medical schools, and demon-
strated unequivocally the power of self-regulation
within the profession.

With the dramatic decrease in the number of
medical schools, from 160 to 60, after the publica-
tion of the Flexner Report, the 1920s saw a
marked decline in the availability of physicians to
treat the rural populace and the poor. Philan-
thropic organizations such as the Rockefeller
Foundation and the Duke Endowment came to
the fore, and in addition to calling for the creation
of new medical schools to meet these needs, they
offered financial incentives as well. Again, a
swing of the pendulum took place.

During the 1930s, both the AMA and the
AAMC began to question the efficacy of creating
more medical schools, and the first suggestions of
the potential of an oversupply of physicians began
to arise. Although no drastic reduction in either
the number of schools or the number of ma-
triculants was implemented, medical schools be-
gan to take a leadership role in actively improving
the quality of their product.

World War II increased the demand for more
physicians, and the federal government not only
pressured medical schools to increase enrollment
to meet the war needs, but with the passage of the
Hill-Burton Act in 1948, which created rural hos-
pitals, and the expansion of the VA hospital sys-
tem, it also insured a domestic need for more
physicians. The AAMC called for an expansion of
the current medical school capacity to educate
physicians, and the Truman Commission of
1949-50 agreed.4

Although the AMA did not actively support the
call for increased class size or the need for new
medical schools in the late 1940s and early 1950s,
they did join with the AAMC in the early 1960s in

May 1989

239

PHYSICIAN MANPOWER

voicing concern over a probable physician short-
age in the near future, which, they suggested,
required immediate action on the part of the
federal government. Immediate action was forth-
coming with the passage of the first Health Profes-
sions Educational Assistance Act in 1963, which
provided money for the construction of new
schools, the expansion of existing ones, and money
specifically designated for medical student loans.5

MEDICARE and MEDICAID were enacted in
1965 and by 1970, the Carnegie Commission
called for a 50 percent increase in medical school
enrollment, with concomitant federal funding, to
meet the perceived need.6 The 1971 Health Man-
power Act provided additional money to existing
medical schools to increase class size and encour-
aged two year schools to add the third and fourth
clinical years. The era of the Great Society had
given birth to what appeared to be a limitless
expansion of medical education capacity aimed at
providing health care through government sup-
port for the great underserved masses.7

However, in 1973, two years after the passage
of the 1971 Health Manpower Act, Caspar Wein-
burger, then Secretary of the Department of
Health, Education, and Welfare, began looking at
the total physician population, the anticipated
graduates of the extant medical schools, and the
numbers of foreign medical graduates coming
into the United States to practice, and he con-
cluded that a potential shortage of physicians no
longer existed, but rather, an oversupply ap-
peared imminent.8

OVERSUPPLY PROJECTIONS IN
RECENT YEARS

In 1979, Joseph Califano, U.S. Secretary of
Health, Education, and Welfare, embraced Cas-
par Weinberger’s conclusion, and warned physi-
cians at the Plenary Session of the Annual Meeting
of the Association of American Medical Colleges
that action needed to be taken immediately to
forestall a serious oversupply of physicians by the
year 2000. He did, interestingly enough, admit
that the potential crisis was due in part to the
zealous efforts on the part of the federal govern-
ment to ward off the projected shortfall of physi-
cians, about which there was much concern in the
1960s.9

One year later the final report of the Graduate
Medical Education National Advisory Committee
(GMENAC) was published. The Committee, es-
tablished in 1976 under the auspices of the De-

240

partment of Health and Human Services, to look
at physician supply from the perspectives of geo-
graphic and specialty maldistribution, concluded
that there was indeed the probability that a sur-
plus of 70,000 physicians would exist by 1990.
However, in some specialties and some geo-
graphic areas, shortages would continue or be-
come apparent. Therefore, graduate medical
education should be considered as one of the key
elements to the formulation of any policy con-
cerning physician manpower.10

The GMENAC was not the only federal mecha-
nism for collecting physician manpower statistics.
The Health Resources Administration via its Man-
power Analysis Branch of the Bureau of Health
Manpower (BHM) had been empowered, under
the Health Professions Educational Assistance Act
of 1976, to collect data on the supply and require-
ments of the physician population. The BHM
report, first published in 1978, also projected an
oversupply of physicians, with the numbers of
active physicians approaching 600,000 by 1990,
compared to 450,000 in 1980 and 525,000 in 1985,
suggesting a net increase of 75,000 every five
years.

Both the GMENAC and the BHM were di-
rected to assess physician supply and require-
ments based on national health needs. The Bureau
of Labor Statistics of the U.S. Department of
Labor undertook the same project with a different
end in mind. Their data collection was directed at
assessing the situation from a national economic
standpoint as input to forecasting the future GNP.
Although cross-profession manpower statistical
measurements had been carried out from the
Bureau’s inception, the Bureau of Labor Statistics
in the late 1970s endorsed the BHM projection
model (called “SOAR,” or Supply Output and
Requirements) as being superior to its own and
accepted its conclusion that an oversupply of phy-
sicians was probable by 1990. 11

In an effort to evaluate the presumption that an
oversupply of physicians would indeed occur by
1990, based on the GMENAC and the BHM re-
ports, the Senate Committee on Labor and
Human Resources requested that the Office of
Technological Assessment (OTA) look at the two
reports to determine whether the conclusions
were valid, and, if so, what recommendations
might be forthcoming. The result of this effort
was a publication entitled Forecasts of Physician
Supply and Requirements.

The Journal of the South Carolina Medical Association

PHYSICIAN MANPOWER

The publication primarily addressed the statis-
tical methodologies used by the GMENAC and
the BHM, the former based on goal-driven, medi-
cal opinion and the latter on trend projections.
Both methodologies, incorporating supply and re-
quirements models, complemented each other,
and both arrived at the same conclusions, specifi-
cally, that an oversupply of physicians appeared
imminent, although certain specialties and locales
might experience shortages. However, the OTA
(1980) qualified its conclusion from the
GMENAC and the BHM reports as follows:

The final and most important observation
is that the forecasting process has remained
too technical a process, where statistical tech-
niques, economic knowledge, and medical
expertise greatly influence the process. Yet,
more often than not, the basic assumptions
adopted in the methodologies are policy
ones. This is particularly true for projections
of the future supply of physicians and deci-
sions on specialty distribution requirements.
Further, policies that have been made and
are under consideration directly impact on
the projections, yet the reliance on historical
data can systematically underestimate the
effects of such policies.12

Numerous other reports concerning physician
manpower projections, both from the public and
the private sectors, have served as catalysts for or
been published since the GMENAC and the BHM
reports. Both the AMA and the AAMC created
task forces to look at the physician supply ques-
tion. In response to the AMA Task Force on Physi-
cian Supply recommendations, the AMA Board of
Trustees embraced a physician manpower re-
search agenda and charged the AMA Center for
Health Policy to undertake the effort. The initial
outcome was the publication of a monograph in
1987 which contained a summary of the previous
attempts to accurately quantify and project physi-
cian manpower as well as an introduction of the
AMA Demographic Model of the Physician Popu-
lation, with concomitant data based on a number
of variables. The underlying conclusion was that
the numbers of physicians would continue to rise
although the rate of gain was indeterminate.

A thrust of the AMA Demographic Model was
to look beyond the obvious when projecting phy-
sician supply. The earlier models were primarily
based on the annual addition of medical school

graduates to the workforce and the decrease in
numbers of physicians based on retirement. One
of the main elements of the AMA Model was the
inclusion of a number of variables into a fluid
model to arrive at a variety of outcomes based on
different scenarios. Among the variables analyzed
were the projected increase in foreign medical
graduates, the trend towards more females en-
tering the profession, the average indebtedness of
medical school graduates, and projected earnings. 13

Each of the variables has been addressed to a
greater or lesser extent in the literature, with the
impact of foreign medical graduates receiving the
most attention. Obviously, if the country were to
allow unlimited immigration of foreign medical
graduates, a physician surplus would certainly
result. The potential problem was addressed with
the passage of the 1976 Health Professions Educa-
tional Assistance Act, which included a provision
to limit such an influx. However, that specific
limitation had certain drawbacks, including the
fact that many foreign medical graduates have
chosen to practice in underserved areas,14, 15 and
that medical services supported primarily
through graduate medical education were often
provided by foreign medical graduates filling
lower paying residencies.16

At the other end of the spectrum, many felt that
in addition to creating a physician surplus, the
migration of foreign medical graduates to the U.S.
portended lower quality of health care,17 a brain
drain from underdeveloped countries contribut-
ing to a world health crisis,18, 19, 20 and a national
policy statement that would undermine the U.S.
commitment to international health.21

Another variable of marked effect on man-
power projection was the trend that increasing
numbers of women were graduating from medi-
cal schools and entering the workforce. Studies
have shown that their productivity has tradi-
tionally not been as high as that of their male
counterparts based on professional leave time
mandated by family commitments. Therefore,
although total numbers of physicians were indeed
increasing, factoring in the lesser amount of time
available to see patients would effectively lessen
the aggregate physician/patient ratio.22, 23

Along those same lines, the changing lifestyle of
the traditionally white male recent graduate will
certainly have a major impact on the changing
marketplace. Both residents and medical stu-
dents, in increasing numbers, are married, with

May 1989

241

PHYSICIAN MANPOWER

the concomitant commitment to family life and
shared responsibility demanded by today ’s gener-
ation of young marrieds, many with two careers.
This again lessens the total work week hours avail-
able to see patients.24

Even potential physician income must be con-
sidered. Recent graduates are now making in-
formed choices upon graduation (or even before)
concerning their practice options, whether group
or solo,25 rural or urban,26- 27 HMO’s or third party
practice management.28

NEW PROJECTIONS: POSSIBLE SHORTAGE

In the early 1980s, Uwe Reinhardt held an
economist’s point of view of the physician surplus
that the demand for physician incomes would
exceed the supply of physician incomes. How-
ever, in his address to the AAMC in November,
1987, he said that, as physician incomes continue
to rise, and with a reduced likelihood of socialized
medicine in the U.S., evidence of physician over-
supply is less than convincing.

As previously mentioned, the AAMC appointed
Task Force on Physician Supply is studying the
manpower problem, and one of its charges was to
look at the projected physician surplus in terms of
identified advantages and disadvantages. Their
findings were summarized in a recent report, and
the conclusions are not surprising. The advantages
to a surplus include: increased health care for the
population with a slight reduction in mortality,
lower unit costs or reduction in price increases,
expanded services (i.e., house calls, more care for
the underserved), increased physician supply in
rural and urban poor areas, reduction in need for
foreign medical graduates, more interest in, and
availability of, physicians for international health
care.

The disadvantages are the use of unnecessary
procedures to increase income, an increase in total
costs of health care due to increase in consumption
(although relative unit costs might decline), not
enough practice to insure high level of skills, a
general undermining of morale, a greater move
towards industrialization of medicine thereby
lessening practice choices, the potential for under-
employment and a decrease in minority oppor-
tunities when the need is increasing.29

The relative advantages and disadvantages of
an oversupply may be moot issues. Two articles in
the April 7, 1988 issue of The Neu) England

242

Journal of Medicine predict a probable shortage
of physicians by the early years of the next cen-
tury. They predict that the demand for physicians
will increase as a result of the aging population,
more competitive medical plans, the impact of
AIDS, the increasing minority population.30- 31
They further address the complexity of attempts
to make long-term predictions concerning physi-
cian manpower and urge caution about establish-
ing policy based on such predictions.

The Council on Graduate Medical Education
held two days of hearings, November 19 and 20,
1987, to receive input from the representatives of
50 organizations about their positions regarding a
number of issues, including the adequacy of phy-
sician manpower. The testimony revealed dis-
agreement about whether or not an oversupply
was imminent. However, there was consensus to
expend greater effort to meet the health needs of
the underserved; and strong recommendations
were made that the federal government adopt a
policy to increase graduate medical education
programs diected towards these goals.32

NEEDED ACTION

Two questions, then, must be asked. Based on
current data and available statistical meth-
odologies, can we accurately project the physician
manpower supply and demand, taking into ac-
count the magnitude of variables that exist in the
current market? And, if such a projection can be
made, which is doubtful, should policy decisions
be made to attempt to influence numerical out-
comes, especially in light of those same variables
that make the basic projections virtually impossi-
ble? Answering these questions requires several
considerations which are discussed below in order
to clarify what steps should be taken.

The American Medical Association, while
maintaining that current trends suggest an over-
supply of physicians by the year 2000, voiced
support of insuring adequate numbers and fund-
ing levels of graduate medical education oppor-
tunities. The AMA concluded that reductions in
numbers of physicians must begin at the under-
graduate medical education level and through
limitations on foreign medical graduates entering
the country. Any attempt to cut back graduate
medical education programs could be severely
damaging to both recent graduates and local
health care. And, consideration should be given to

The Journal of the South Carolina Medical Association

PHYSICIAN" MANPOWER

increased funding to reduce requisite weekly
hours of residencies.33

The statement of the Association of American
Medical Colleges34 complemented that of the
AM A. The AAMC endorsed the concept that edu-
cation must be the primary goal of residency
training and that adequate funding levels for such
education must be maintained. It also concurred
with several of the principles of the Council on
Graduate Medical Education, namely that steps
must be taken to develop and finance alternative
educational programs for residents in non-hospi-
tal settings, and that emphasis must be given to
encouraging specialization in primary care resi-
dent education to meet the growing needs of
society.

The first of ten principles of the Council on
Graduate Medical Education, circulated prior to
the open hearings, stated that: “The primary con-
cern of the Council must be the health of the
American people. There must be assured access
for all to quality health care. Concern for the well-
being of the health professions, medical schools,
and teaching hospitals, while important must be
secondary to the above concerns.”'35 The AAMC,
as well as the American Medical Student Associa-
tion, did take issue with this statement, suggesting
that there was actually a causal relationship be-
tween the two, with a vital health care system
being necessary to insure a healthy populace.

The Council’s recommendations for public pol-
icy emphasize graduate medical education as vital
to the health of the community. No recommenda-
tions were put forth for broad changes in total
numbers of residency positions.

Another policy recommendation suggested by
the AAMC Committee on Implications of Physi-
cian Supply for Resident and Fellow Education,36
was that a physician manpower projection model
be created, predicated on demand or market
economy, and that this model be used to analyze
physician supply on a regular basis. The data
collected could be used, especially, in the determi-
nation of geographic or specialty needs; and steps
could then be undertaken to alleviate identified
shortages.

The underlying universal assumption here is
that an oversupply in any particular area of the
economy would be self-correcting, as is usually
the case in a capitalistic society, and that federal
policy is mandated only as a corrective measure to

support the underserved. This concept can be as
readily applied to a service industry as to a prod-
uct-based one, and, in general, has held true for
the medical profession as well.

Both the government and the medical profes-
sion have spent a great deal of time, effort and
resources on the process of projecting physician
supply and demand, the potential ramifications of
the data collected, and the impact of the outcomes
on graduate medical education. That a problem
exists (beyond certain geographic and specialty
areas) has as yet to be ascertained. And without a
problem, any steps taken to “correct” one could
have broad negative repercussions for future
health care and the profession that serves it.

Graduate medical education is endemic to the
education of future physicians. Change in meth-
odology is probable, and even desirable, given the
fluctuations of today’s society, the need for more
primary care physicians, and even the changing
lifestyle of the recent medical school graduates
themselves. But change does not portend cutbacks
in opportunity, nor in the political, philosophical,
and financial commitments to graduate medical
education.

IMPLICATIONS FOR THE STATE
OF SOUTH CAROLINA

South Carolina has been forward thinking
about these issues. Having recognized the pen-
dulum swings, the statewide Consortium of
Teaching Hospitals (South Carolina Area Health
Education Consortium — S. C. AHEC) stopped
short in 1986 from declaring an oversupply of
physicians in this state. Rather than take action to
change, the Consortium chose to more carefully
monitor the situation longitudinally. Taking the
broader view seemed advisable in 1986, and the
1988 New England Journal articles have sup-
ported the view.

So how is the state regarding the physician
manpower condition0 There are now in excess of
500 positions going unfilled. Through the AHEC
system, the S. C. Hospital Association, the S. C.
Primary Care Association, the S. C. Department
of Health and Environmental Control and others,
the state is stepping up recruitment and retention
efforts and seeking to thoroughly investigate be-
fore moving to increase or decrease the number of
physicians being trained.

The Ervin Report called for the Consortium “to

May 1989

243

PHYSICIAN MANPOWER

observe physicians (longitudinally) in their prac-
tice environment, monitor trends in their produc-
tivity levels and make note of possible changes in
the patient pool.”37 This project will provide em-
pirical evidence needed to better assess manpower
needs and projections for graduate medical edu-
cation. This AHEC project involves both state
medical schools and all community teaching hos-
pital residency programs. Other efforts are al-
ready under way addressing physician manpower
and maldistribution. Therefore, the state has a
mechanism for addressing the issue through the
S. C. AHEC.

The mechanism needs to be fully deployed
with the goal to establish a clear policy to govern
decisions about the number of programs and resi-
dents and state support for graduate medical edu-
cation. In addition to the S. C. AHEC with the two
medical schools, the non-teaching hospitals, the
Commission on Higher Education and the S. C.
Medical Association should provide input in for-
mulating this policy.

The need is great for a broadly-based and ac-
cepted state policy on graduate medical educa-
tion, especially in light of growing costs at a time
when federal dollars are shrinking. This policy
will help insure that South Carolina continues to
prosper in providing health care for its citizens. □

REFERENCES

1. Packard, FR: History of Medicine in the United States.
New York: P R. Hober, 1931.

2. American Medical Association. Council on Medical Edu-
cation: History of accreditation of medical education pro-
grams. JAMA 250: 1502-1508, 1983.

3. Flexner, A: Medical Education in the United States and
Canada: A Report to the Carnegie Foundation for the
Advancement of Teaching. New York: Arno Press, 1910.

4. Ginzberg, E, Brann E, Hiestand, D, Ostow, M: The ex-
panding physician supply and health policy: The clouded
outlook. Milbank Q 59: 508-541, 1981.

5. Hiller, MD, Schmidt, RM: Physician training: More than a
legislative issue. Am J Public Health 66: 996-997, 1976.

6. Carnegie Commission on Higher Education: Higher Edu-
cation and the Nation’s Health: Policies for Medical and
Dental Education. New York: McGraw-Hill, 1970.

7. Wilson, MP: Medical schools in the planning stage: Are
more schools needed? J Med Educ 47: 677-689, 1972.

8. Anlyan, WG: Overview of public and private policies
affecting physician supply in the U.S., in Yaggy, D,
Hodgson, P (eds): How Many Doctors Do We Need ? A
Policy Agenda for the United States in the 1990’s. Dur-
ham, NC: Duke University Press, 1986, pp 1-8.

9. Califano, JA: The government-medical education part-
nership. J Med Educ 54: 19-24, 1979.

10. U.S. Department of Health and Human Resources, Health
Resources Administration: Report of the Graduate Medi-

244

cal Education National Advisory Committee, Volumes I-
VII. Washington, D. C.: United States Government Print-
ing Office, 1980.

11. Jacoby, I: Physician manpower, GMENAC and after-
wards. Public Health Rep 96: 295-303, 1981.

12. Office of Technology Assessment, Congress of the United
States: Forecasts of Physician Supply and Requirements.
Washington, D. C.: United States Government Printing
Office, 1980, p 11.

13. AMA Center for Health Policy Research: The Demo-
graphics of Physician Supply: Trends and Projections.
Chicago: American Medical Association, 1987.

14. Hambleton, JW: Foreign medical graduates and the doc-
tor shortage. Inquiry 9: 68-72, 1972.

15. Schaffner, R, Butler, I: Geographic mobility of foreign
medical graduates and the doctor shortage: A longitudinal
analysis. Inquiry 9: 24-33, 1972.

16. Way, PO, Jensen, LE, Goodman, LJ: Foreign medical
graduates and the issue of substantial disruption of medi-
cal services. New Eng J Med 299: 745-751, 1978.

17. Feldstein, PJ, Butler, I: The foreign medical graduate and
public policy: A discussion of the issues and options. Int J
Health Serv 8: 541-558, 1978.

18. Bowers, JZ, Rosenheim, Lord (eds.): Migration of Medical
Manpower. New York: Josiah Macy, 1971.

19. Gish, O, Godfrey, M: A reappraisal of the “brain drain" —
with special reference to the medical pofession. Soc Sci
Med 13C(3): 1-11, 1979.

20. Senewiratne, B: The emigration of doctors: A problem for
the developing and the developed countries. Part II. Br
Med J 1975(1): 669-671, 1975.

21. Asper, SP: The ebb and flow of physician migration:
America needs a new policy. Bull NY Acad Med 62:
980-987.

22. Adams, KE, Bazzoli, GJ: Career plans of women and
minority physicians: Implications for health manpower
policy. J Am Med Worn Assoc 41(1): 17-20, 1986.

23. Bowman, M, Gross, JL: Overview of research on women in
medicine — Issues for public policy makers. Public Health
Rep 101: 513-521, 1986.

24. Nicholson, B: Life-style choices and evolving practice
patterns in Yaggy, D, Hodgson P (eds): How many doctors
do we need? A policy agenda for the United States in the
1990’s. Durham, NC: Duke University Press, 1986, pp
34-36.

25. Goodman, LJ, Nash, KD: Conditional logit analysis of
physicians’ practice mode choices. Inquiry 19: 262-270,
1982.

26. Chen, MK: Health care services and health status in a rural
setting: The utility of some predictors. Inquiry 19:
257-261, 1982.

27. Fruen, MA, Cantwell, JR: Geographic distribution of phy-
sicians: Past trends and future influences. Inquiry 19:
44-50, 1982.

28. Ginzberg, E: From Physician Shortage to Patient Short-
age: The Uncertain Future of Medical Practice. Boulder,
CO: Westview Press, 1986.

29. Association of American Medical Colleges. Task Force on
Physician Supply: Reflections on the advantages and dis-
advantages of an abundance of physicians, 1988.

30. Schloss, EP: Beyond GMENAC — Another physician short-
age from 2010 to 2030? New Eng J Med 318: 920-922,
1988.

31. Schwartz, WB, Sloan, FA, Mendelson, DN: Why there will
be little or no physician surplus between now and the year
2000. New Eng J Med 318: 892-897, 1988.

32. Council on Graduate Medical Education: Summary of
public hearing: November 19-20, 1987.

The Journal of the South Carolina Medical Association

33. American Medical Association: Statement of the Ameri-
can Medical Assocation to the Council on Graduate Medi-
cal Education, 1987.

34. Association of American Medical Colleges: Statement of
the Association of American Medical Colleges on cognate
issues presently before the Council on Graduate Medical
Education, 1987.

35. Council on Graduate Medical Education: Summary of
public hearing: November 19-20, p 3, 1987.

36. Association of American Medical Colleges. Committee on
Implications of Physician Supply for Resident and Fellow
Education: Report, 1988.

37. Ervin, FR, Kennedy, DB: A Report to DMEC/Physician
Manpower Committee on the Physician Manpower
Study’s Primary Care Recommendations, 1987, p 5.

MEETING

ANNOUNCEMENT

South Carolina Chapter
American Academy of Pediatrics
Annual Scientific Session

“Pediatric Update”

Faculty: Frank A. Oski, M.D., Heinz F.
Eichenwald. M.D., William B. Strong,
M.D.

Meeting Site: The Grove Park Inn,
Asheville, North Carolina

Meeting Dates: Thursday, August
3-Sunday, August 6, 1989

Credit: AMA Category I and PREP, 6
hours.

For more information contact: Debbie Shealy, SC
Chapter AAP, P.O. Box 11188, Columbia, SC
29211, (803) 798-6207.

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May 1989

245

FAMILY PRACTICE.

A REWARDING EXPERIENCE IN
ARMY MEDICINE.

The Army has more soh
diers with families than ever
before. So when you join the
Army Medical Team as a Fam-
ily Practitioner, expect to
spend most of your time serv-
ing not only soldiers, but their
spouses and children, too.

What’s more, you won’t have
to worry about the paperwork,
malpractice insurance pre-
miums, or the costs incurred
in running a private practice.

Expect to work in a
highly challenging and varied
environment. Working with a
team of highly trained profes-
sionals, you can receive
assignments almost anywhere

in the United States; the Army offers the largest system of comprehensive
health care in the nation. Family Practice positions are also available overseas,
in Germany and Korea.

The benefits package available to Army Family Practitioners is quite
attractive. You’ll receive 30 days paid vacation, opportunities to continue edu-
cation and conduct research, a chance to travel, and reasonable work hours.

All in all, your Army Family Practice will be a rewarding experience. Not
only for you, but for Army families, too. Talk to your Army Medical Depart-
ment Counselor for more information.

FEDERAL OFFICE BLDG.

816 WALKER ST., RM. 208
AUGUSTA, GA 30901-2350
(404) 724-7506 COLLECT

ARMY MEDICINE. BE ALL YOU CAN BE.

246

The Journal of the South Carolina Medical Association

In this issue of The Journal, McGowan and Cleghorn comment on graduate medical education in
South Carolina. To complement this article, the deans of both of our state s medical schools were invited
to comment on the development of policy regarding medical education in South Carolina. In the
editorials below, Dr. G. William Bates points out that our state has been among the nation s leaders in
efforts to predict the supply-and-demand of future physicians, while Dr. J. O’Neal Humphries
emphasizes the present and future role of the Joint Board for Health and Medical Education established
in 1983.

Dr. Bates’ editorial was written shortly before his resignation from the position as Dean at the
Medical University of South Carolina. In wishing Dr. Bates well in his future endeavors, it seems
appropriate to thank him not only for his able service to the Medical University but also for his interest
in the SCMA and in The Journal.

Guest editorials reflect the opinions of the authors and do not necessarily reflect the opinions of the
Editorial Board or the leadership of the South Carolina Medical Association.

— CSB

POLICY DEVELOPMENT FOR MEDICAL EDUCATION
IN SOUTH CAROLINA

In this issue of The Journal, McGowan and
Cleghorn review the changes occurring in under-
graduate and graduate medical education. Na-
tional attention on medical education has been
focused on physician supply and demand for the
21st century.

I was a member of the Association of American
Medical Colleges Task Force on Physician Supply
(1987-1988) that was charged to evaluate physi-
cian manpower needs. After several lengthy
meetings in Washington, D. C., our committee
was unable to come to any clear conclusions about
physician supply and demand for the 21st cen-
tury. Because of changes in practice patterns, the
occurrence of new illnesses (e.g. AIDS), the in-
creasing number of women physicians, and the
technological advances in medicine, manpower
projections are — at best — shaky speculation.

South Carolina has been a leader in attempting
to predict state need for physicians. In 1985 a
consensus decision was made to reduce the
number of matriculating students at the Medical
University of South Carolina from 165 students
per year to 125 students per year. At the same
time, a decision was made to increase the number
of students admitted to the University of South

Carolina School of Medicine to 75 students per
year. Thus, it was expected that 200 physicians
would be graduated annually from the two South
Carolina medical schools. This decision makes
sense.

Given the population of South Carolina and
given the fact that most matriculants to South
Carolina medical schools are South Carolina resi-
dents, 200 medical students each year should en-
sure a qualified applicant pool and an adequate
number of graduate physicians. Moreover, this
decision makes classes in the two schools small
enough to provide students with individual fac-
ulty attention.

Medical education does not end when the de-
gree of Doctor of Medicine is conferred. Medical
education continues for another three to seven
years to produce primary care physicians and
specialists in the various fields of medicine. South
Carolina is farsighted by making financial provi-
sion for graduate medical education, and should
continue this support into the future.

There should be a balance between the number
of graduating physicians and the number of resi-
dency positions available for graduating physi-
cians. In 1989, 187 first-year graduate medical

May 1989

247

education positions were available in South Caro-
lina through the two medical schools and the
AHEC practice sites. This is close to an even
balance, although an additional 13 positions
should be added in the future to attain equi-
librium. Otherwise, South Carolina will export 13
physicians annually.

Of the graduate medical education positions
available, 53% are in primary care specialties
(family medicine 29%, internal medicine 16%,
pediatrics 9%). The remaining 46% of the resi-
dency positions were offered in the other spe-
cialties of medicine.

It is my opinion that South Carolina has made a
rational estimate of physician manpower needs.
However, the future must be viewed with caution.
As physician supply and demand changes in South
Carolina, we must stand ready to make appropri-
ate changes in undergraduate and graduate medi-
cal education.

— G. Willam Bates, M.D.

Dean, College of Medicine
Medical University of South Carolina
Charleston, S. C.

WORKING TOGETHER MAKES SENSE AND PROGRESS

The state of South Carolina has made remark-
able progress over the past 20 years in the area of
graduate (medical school) and postgraduate (resi-
dency training) medical education.

In 1974, the statewide Family Practice Resi-
dency Program was established in the six commu-
nity teaching hospitals located in Columbia,
Greenville, Spartanburg, Anderson, Greenwood,
and Florence.

In 1975, student elective opportunities for the
students of the College of Medicine of the Medical
University of South Carolina (CM-MUSC) were
established.

In 1977, the second medical school, the Univer-
sity of South Carolina School of Medicine (USC-
SM), located in Columbia, admitted its first
students.

In 1978, state funding to provide some of the
costs of residency training other than in Family
Practice was established under the program
known as “Graduate Doctor Program.”

In 1983, the Joint Board for Health and Medical
Education (Joint Board) was established as a vol-
untary cooperative effort between the Medical

248

University of South Carolina and the University of
South Carolina. This group has developed a plan
for adjusting the number of medical students ad-
mitted to the two schools each year. It has been
agreed that about 125 students will be admitted to
the school in Charleston yearly and about 75
students admitted to the school in Columbia
yearly. These figures were accepted by the Joint
Board following two surveys and studies to iden-
tify the proper number. This number of 200 medi-
cal students between the two medical schools was
based on the number of South Carolinians inter-
ested in obtaining a medical education, the finan-
cial burden on the state, and the need for
physicians in South Carolina, especially rural
South Carolina.

The Joint Board is in a position to regularly
review all of these factors and adjust the numbers
of medical students as it seems appropriate for the
needs of South Carolina. Recently, the Joint Board
agreed to support the CM-MUSC development of
an M.D./Ph.D. program to train medical scien-
tists. It is now appropriate that a process be devel-
oped to study the need for residency positions

The Journal of the South Carolina Medical Association

throughout the state. This process would attempt
to respond to the dynamic shifts in physician
manpower needs and distribution in the state of
South Carolina. It would address the numbers and
locations of the various specialty and subspecialty
residency training programs within the state. It is
appropriate for the residency training site, in co-
operation with the two medical schools, to de-
velop a plan for such a process and then present
this plan to the Joint Board for approval. It may be
necessary to establish a consultant group to help

develop the plan.

I strongly support an organized planning pro-
cess to develop a policy on residency training. This
would help avoid a haphazard growth of various
programs dictated more by local self interest than
on statewide needs.

— J. O’Neal Humphries, M.D.
Dean, School of Medicine
University of South Carolina
Columbia, S. C. 29208

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PHYSICIAN RECOGNITION AWARDS

The following SCMA physicians are re-
cent recipients of the AMA’s Physician Rec-
ognition Award. This award is official
documentation of Continuing Medical Edu-
cation hours earned.

U. Hoyt Bodie, M.D.

Rosalie E. Browning, M.D.

Wayne G. Entrekin, M.D.

William R. Greene, M.D.

Charles W. Hinnant, M.D.

Michael J. Malone, M.D.

Randy D. Watson, M.D.

Walter D. Wright, M.D.

May 1989

249

PROMOTE AIDS
EDUCATION

AMA MEDICAL
STUDENT SECTION
T-SHIRT SALE

Wear the t-shirt that promotes
AIDS education. The t-shirts'
slogan "Spread the Word,
Not the Disease - AIDS"
reflects the Medical Student
Section's ongoing commitment
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Section sponsors a community
action program "AIDS
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medical students help educate
adolescents about AIDS.

The t-shirts are bright red and
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Please enclose a $10.00
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ON THE COVER:

DOGWOOD (CORNUS FLORIDA)

In addition to its role as a beautiful harbinger of
spring in the Carolinas, the dogwood in the 19th
century was much prized for its wide variety of
properties. Its medical uses were purported to be
in the treatment of intermittent fevers; as a “most
efficient substitute for quinine, in treating malar-
ial fevers”; mixed with whiskey, a remedy for low
forms of fevers and dysentery occurring near
river swamps; as an astringent tonic; as a cathartic;
and as a substitute for chamomile tea. The bark
was used to treat a malignant disorder of horses
called yellow water. A fine writing ink was made
from the gallic acid in the bark, and the Indians
extracted from the roots a scarlet dye. The wood,
compact, heavy, fine grained, takes a brilliant
polish, and was used on plantations for wedges,
tool handles, mallets, horse collars, etc. Young
shoots were used for hoops of small casks, and at
times the cogs of mill wheels were made of the
wood. Dr. Porcher said that he had used the hard
wood of the dogwood for engraving, and Dr.
Lindley reports that the young branches, stripped
of their bark, and rubbed against the teeth, render
them extremely white.

All in all, a most excellent plant.

Betty Newsom

The Waring Historical Library

(Plate from Bigelow’s American Medical Botany, 1818.)

250

The Journal of the South Carolina Medical Association

PRESIDENT’S INAUGURAL ADDRESS
DANIEL W. BRAKE, M.D.
APRIL 29, 1989

It is indeed a privilege for me to stand before you tonight as your new President.

Growing up in Lake City, South Carolina, I was greatly influenced by my uncle, Dr. Dexter Evans, a
general practitioner who dedicated his life to the sick. In the absence of a hospital, Uncle Dec made rounds
in his patients’ homes. Most of his holidays were interrupted by patients requiring care. He was available
24 hours a day, seven days a week. His type of dedication and devotion is something this generation does
not have to bear. He died of carcinoma of the lung when I was in medical school. I have never been to a
funeral where I have seen more community response and love. The church was packed; the church yard
and streets were full of people showing their respect to a man who had devoted his life to them. I could
never begin to fill his shoes, but I knew as a child that I wanted to be a physician.

When I received my M.D. degree, I realized that this was a gift I should cherish. There are so many
people who play a part in our education. When we take the Hippocratic Oath we are accepting a
tremendous responsibility. I believe our medical responsibilities should be

First, to provide quality medical care for the sick.

Second, to discipline ourselves to insure that quality.

Third, to be an observer and spokesman for health care and insure access to quality care for all
Americans.

And last, but certainly not the least — to become involved in organized medicine. THIS IS THE ONLY
WAY WE CAN FULFILL ALL OF THE OTHER RESPONSIBILITIES.

It is not enough for us to take our M.D. degree and use it for our own benefit. It is important for us to give
something back to the system which shaped us. Let’s look at each responsibility:

1. OUR FIRST RESPONSIBILITY IS TO PROVIDE QUALITY MEDICAL CARE FOR THE SICK.
Our oath is a public promise to be competent and to use that competence in the interest of the sick. Our
medical knowledge has been passed on by our forefathers in medicine. Much of this knowledge has been
gained by observing and treating generations of sick people. The state has contributed considerable funds
to our education, approximately $240,000 per student at this time. We must not forget that the sick person
is in a “uniquely dependent, anxious, vulnerable and exploitable state.” Therefore, the physician’s
knowledge is not individually owned and should not be used primarily for personal gain, prestige or
power. Rather, the profession should hold this knowledge in trust for the good of the sick. I am appalled
and ashamed of the few physicians who have taken this degree and the respect it holds and tarnished it
with their get-rich-quick clinics.

2. OUR SECOND RESPONSIBILITY IS TO DISCIPLINE OURSELVES TO INSURE THAT QUAL-
ITY. I think the time has certainly come for us to clean up our own house. Beginning in the mid-1970s
while the PRO was reviewing for federal insurance programs, the SCMA had its own peer review
committee to review for private insurance carriers. The committee saw cases of physicians who grossly
over-utilized services and practiced poor quality medicine. It was an extremely effective committee. Now

Mav 1989

253

PRESIDENT’S PAGES

that we have what we feel will be a fair and effective PRO in South Carolina again, it is time to reactivate
our own peer review committee for private insurers and to give fair warning that the SCMA will be looking
closely at physicians who are not honoring their oath.

3. OUR THIRD RESPONSIBILITY IS TO BE AN OBSERVER AND SPOKESMAN FOR HEALTH
CARE AND TO INSURE ACCESS TO QUALITY CARE FOR ALL AMERICANS. In observing the
health care industry, we find major problems with government interference, growing numbers of
uninsured or inadequately insured patients, and a smaller percentage of private-pay patients. It is my
belief that we are currently heading toward a completely government controlled or socialized system. If
we do not get all the parties involved and come up with a recommendation to alter the current trend, we
will all be working for the government in the near future.

Let me give you some statistics that will confirm my projections. In 1965, Congress decided that we
needed a health care system for the elderly and passed the Medicare law. The AMA lobbied heavily to try
to convince Congress that Medicare should only cover the people who need it and let the wealthy pay for
their own health insurance. As you know, from our deficit spending, Congress is eager to give away money
they don’t have in order to get votes. So, instead of accepting the AMA’s recommendation, Congress passed
Medicare and included everyone over 65 regardless of income. But when Medicare was passed in 1965, the
life expectancy was 69.5 years. At that time it appeared that on the average Medicare would only have to
provide health care for people from age 65 to 69. That life expectancy has now increased to 75 years, and
the Medicare enrollees have expanded from 15.5 million to 30 to 35 million. In 1965, we had 12 working
people to pay for each Medicare recipient. We are now down to four. In the next decade that number will
be two.

When Medicare was initially passed in 1965, reimbursements to hospitals and physicians were equal to
private insurance companies. Over the past 24 years we have seen Medicare continue to demand the same,
if not better, services — only to pay less than the private sector pays for those services — and in some
instances even less than it costs to provide them. Yet, prior to 1965, there was a segment of the population
that didn’t pay their bills, but that percentage was relatively small. Everyone paid a little more for his
medical bills to cover the people who could not pay. We took care of anyone who walked into our offices.
No one was refused because he could not pay a bill. Just recently, to insure that the Medicare patient in the
150th percent of poverty level would not hesitate to come to a physician, the SCMA implemented a
Personal Care plan which guarantees acceptance of assignments for these patients. The majority of
physicians today do not turn people away because they cannot pay for their care.

Of course, as the number of Medicare patients increases, the percentage of the full-paying patients
decreases. In 1987, Medicare and Medicaid accounted for 47 percent of all hospital admissions and 53
percent of all hospital days. The Hospital Association tells me that now if a hospital has over 55 percent
Medicare and Medicaid patients, that hospital is in financial trouble. We are seeing a number of quality
hospitals, especially small hospitals, in financial trouble at the present time. It is not hard to understand
that if the hospital is receiving only 50 cents on the dollar for 47 percent of its patients, then the private-pay
patients will have to pick up that extra 50 cents plus pay their own full dollar of service. That is one of the
reasons hospital insurance premiums are skyrocketing. One hospital administrator told me recently that he
will have to increase his rates to the private patient by 30 percent next year to account for the losses from
Medicare and Medicaid.

Of course, as the premiums for hospital insurance continue to rise, the lower socioeconomic group that
previously provided its own health insurance cannot afford it. Thus, a larger segment of the population is
uninsured. Approximately 35 million Americans have inadequate insurance or no health insurance at all.
Of that number, 49 percent are working adults, 33 percent are children under 18 and only 18 percent are
non- working adults. Of course, that continues to decrease the percentage of paying patients. Big business is
screaming because they are the ones picking up the tab for all these government patients who are
inadequately funded.

On the other hand, there are approximately 300,000 millionaires over 65 in this country who don’t need
Medicare who should be paying at least as much for their hospital premiums as the poor, hard working,
lower socioeconomic group. I know when I mention “means testing” for the elderly, they get upset. But as

254

The Journal of the South Carolina Medical Association

PRESIDENT’S PAGES

deserving as the elderly are of medical services they haven’t “paid for them” as they contend. Their
premiums only paid for 23 percent of Part B services this past year. The other 77 percent of those services
were financed through the general fund — your income tax and mine. The average retiree can expect to
receive $28,255 in Medicare benefits after having paid only $2,640 in Medicare taxes. Income taxes pay
the other $25,615. It is no wonder the AARP is so vocal. George Bernard Shaw described this situation
perfectly when he said, “When the government robs Peter to pay Paul, it can always count on the support
of Paul — always.” I know this is not a popular statement to make to our elderly citizens, but if they don’t
start paying their fair share for their health care — and they are costing more for health care than the under
65 — then we will continue to see a shift in our health care system toward more government control.

With our health care system in turmoil, Congress is getting constant complaints from all segments of the
system:

1. The Medicare recipients complain because they are having to pay too much out-of-pocket money.

2. The working class complains that health insurance premiums cost too much.

3. Hospitals complain about poor reimbursements.

4. Physicians complain that Medicare is unfair, and in my opinion, uses unconstitutional tactics and
harrassments such as DRGs; mandatory assignment for physicians in some states — and their numbers are
growing; a fee freeze since 1984; MAACs; “explanation of benefits” letters, otherwise known as EOBs; and,
of course, the hassle for years regarding laboratory reimbursements for physicians’ offices.

We are being forced to provide a service for less than it costs us to provide it. Since 1965 we have seen the
gap grow wider and wider between our Medicare charges and what Medicare allows. Since the freeze in
1984 we have seen another gap develop between what we are allowed to charge a Medicare patient and
what we charge our private patients. Because of this gap, when you turn 65 and receive Medicare, you
automatically receive a 20 percent discount on your physician’s charge as opposed to his other patients —
even if the physician is not a participating physician. That loss in revenue is automatically shifted to the
other patients. It is very difficult to understand how the government can pass a law making it illegal for us
to charge an over-65 millionaire the same fee that we charge a struggling 20 to 30-year-old patient.

This is not the kind of system we need, and this is not the kind of system our patients deserve. We need to
restructure the Medicare law to include only those people who need it. Instead, we are seeing a continued
growth of government-covered patients which is why I fear we are rapidly heading toward a socialized
system.

Let’s take a minute to look at a socialized system we hear is successful — the Canadian system. We
recently had three Canadians at an AMA Leadership Conference: Dr. John O’Brien-Bell who is President
of the Canadian Medical Association; Dr. Leo-Paul Landry, Secretary General; and Dr. Hugh Scully, an
Executive Committee member. In the Canadian system, as with Medicare in this country, the first decade
was marked by expansion. Every time there was another election there was another benefit, and Medicare
was followed by Denticare and Homecare and Long Term Care and Pharmicare. However, as in most
government programs, in 1984 there was an enormous federal budget deficit and things began to change.
The physicians found themselves trapped between the public’s expectation of continued, unlimited care
and the federal government’s determination to lighten its financial load. Since the politicians would not
take the blame for their extravagant promises, they claimed the physicians and patients were abusing the
system. The mood in Canada is rapidly changing and the politicians no longer talk about unlimited
comprehensive care. Now they talk about the best health care the province can afford.

As the present health care system grows older in Canada as it has in Great Britain, there are sometimes
waits of months — that once were weeks — that will soon grow into years. For example, hip replacement can
involve waits of almost one year. There is one lithotripter in the entire province of Ontario, which contains
40 percent of Canada’s population and wealth. Now the wealthy patients travel to Boston and New York
for treatment. If the present Canadian system is so good, why would wealthy patients travel to America for
treatment? Where would Americans travel if we had the same system? At the present time, the Canadian
medical system and three provincial medical associations are in courts trying to prevent the government
from restricting the entry of new physicians into practice, forcing physicians to retire early and capping
physician fees.

May 1989

255

PRESIDENT’S PAGES

Our Canadian friends at the AMA Leadership Conference told us that recently the cost crunch and the
extension of waiting periods has been disheartening. Dr. Scully felt that the stress of making decisions
about allowing open heart surgery patients to wait six months or longer is greater than the stress of
performing the surgery. Dr. Landry was concerned about the great anxiety among physicians because the
system is controlled by the state and the physicians do not know in what direction the state is going. They
feel they are locked into a system over which they have no control. Sound familiar? The government’s plan
to provide health care for everyone is certainly altruistic, but once they are unable to pay for the promises
they make, then they begin implementing unfair rules and regulations that you and I are experiencing
through Medicare. Once the government begins taking these questionable tactics, then I think we would
all agree with Leo Tolstoy when he said, “Government is an association of men who do violence to the rest
of us.”

I think the time has come for us to ask ourselves for our children and the future doctors and patients in
this country, “Do we want a socialized system in America?” If that is not what we want, then I think it is
extremely important for us to take the next step in fulfilling the responsibilities about which I have been
talking tonight, and that step is TO BECOME INVOLVED IN ORGANIZED MEDICINE. It’s time for us
as physicians to sit down with all the parties involved — organized medicine, government, hospitals,
insurance companies, and the over 65 and under 65 patients — to discuss this problem. It’s time for us to
head toward a system with most of us paying what we can afford to pay for insurance premiums, the
government taking care of those who are unable to take care of themselves, and some type of risk pool for
people who are high-risk because of medical problems. I am, therefore, calling for an ad hoc committee
this year which will include all of these groups and which will be asked to come up with a recommendation
for Congress. At the end of the year, I will report back to the House of Delegates with that
recommendation.

With all of us working together, we can fulfill our responsibilities. We can continue to provide quality
medical care for the sick; we can discipline ourselves to insure that quality; we can be observers and
spokesmen for health care and access to that care. But — we must become involved in organized
medicine — from the county societies — to the state level — to the AMA. Only in this way can we alter the
growing trend towards socialized medicine. Only by becoming involved can we continue to remember
with pride the dedication and devotion of those physicians who came before us. Only by becoming
involved can we continue — with pride and dignity — to practice medicine with that same kind of
dedication and devotion.

Again, let me thank you for allowing me to serve as your President. I pledge to represent you to the best
of my ability.

Daniel W. Brake, M.D.
President

256

The Journal of the South Carolina Medical Association

SOUTH CAROLINA MEDICAL ASSOCIATION

AUXILIARY

WE’VE GOT IT!

Today I stand before all of you overwhelmingly cognizant of the high honor you have bestowed upon
me. I thank you for your trust and accept with total commitment. It is truly a thrill of a lifetime with just
one, two — three exceptions — my husband, Bill and our two daughters, Erin and Rachael. It is because of
Bill, his choice of profession, his commitment to it, his integrity and compassion that I represent him to this
organization.

1988 has been a great year for the South Carolina Medical Association Auxiliary. Under the highly
organized leadership of Mary James, the medical auxiliary has flourished and grown — Your dedication as
volunteers has made it so.

When I reflect on the many auxilians I have met working diligently on every level of our organization, I
am amazed at the infinite variety of innate talents, gifts and abilities you possess. Intelligence, motivation,
creativity, initiative, commitment. I also marvel at the expertise and acquired skills which have evolved
from higher education and experience. If our auxiliary is to remain vital and relevant we must be sensitive
to new trends, shifting priorities and different ways of thinking. People are joining organizations for
different reasons than they once did. We also are competing for volunteers’ time. Personal development
and quality programming and projects are essential to attract members of every generation.

I am aware of the unique privileges and opportunities physician spouses have because of who we are.

I know the benefits of having access to information and resources ... of having easy entre to other
organizations, institutions, agencies . . . we have made our mark on health related issues in our
communities.

While we have enjoyed another year of unprecedented successes at the state and county levels, there is
no room for complacency among any of us.

If we are to continue “to improve the quality of health care in South Carolina and enhance the image of
medicine,” we must support the medical profession and portray to the public a reflection of the caring,
concerned, compassionate physicians we represent.

As a body of people working together, in unity, our medical group cannot be taken advantage of — as a
block of registered voters we are to be listened to — and heeded well. Working together as one strong,
unified voice we can and do influence far-reaching decisions and become less vulnerable to outside forces.
The old adage “A house divided will surely crumble. . . .’’is for us a truism. We have all seen what has
happened to medicine when opposing forces split us apart. Most recently, in this past election, we have
seen what we can do for ourselves when we stand together — when we stand unified.. Our numbers do
count.

If our members are not informed, we must educate. If our members, their families, and yes, their office
staffs are not registered to vote and are not voting, we must strongly encourage them — to enlighten them.

May 1989

257

AUXILIARY PAGES

Membership is the backbone of this and any organization. Membership is that integral part, that special
component that runs this auxiliary — smoothly. Our increased numbers not only add people to committees;
AMA-ERF, health projects, legislation . . .; but also increase the number of informed medical families.

Our professional family is at a turning point. It is time now for all of us to commit ourselves to our
families and to our own personal health. It is time to take very good care of ourselves and each other — to
nurture our own medical family. The leadership of this auxiliary is committing itself to you — to place in
your hands tools to help you run your county organizations and thoughts to further stimulate interest. I am
requesting all of you to commit extra time per week to our auxiliary — a few more minutes of your valuable
volunteer time — commit it in some way to the medical auxiliary.

Dickens captures something of the modern medical scenario in the opening line of his classic epic, A
Tale of Two Cities; “It was the best of times, it was the worst of times.” Turbulence, uncertainties, and
changes all are hallmarks of medicine today. High technology and scientific knowledge are pitted against
moral and ethical questions never before asked. A suit-happy society no longer accepts with grace or
reason some of life’s hard facts — some babies are born deformed, some diseases are incurable and the
Creator did not design mortal man to live forever.

If ever our professional family needed our support and encouragement, it is now. The South Carolina
Medical Association Auxiliary, like no other group of individuals or organizations, has the potential to
fulfill needs. We’ve got it! The ability, the skills, and the insightful knowledge. We’ve got it! I thank you
and look forward to an exhilarating year.

Mrs. William Meehan (Robin), President
SCMA Auxiliary

258

The Journal of the South Carolina Medical Association

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“IF YOU DON’T LIKE THE SYSTEM . .

On April 29, when I was installed as President of the SCMA and Tommy Rowland placed the
SCMA medallion around my neck, I felt sincerely humble and proud. But I felt sadness as well, for I
was reminded that this medallion which your president wears at all official functions has the SCMA
seal on the front and the following inscription on the back: “This presidential medallion is given by
John Dessaussure Gilland, Jr., M.D., President, in memory of John Dessaussure Gilland, III, who
died May 5, 1976 at the age of 20 years.” It was on that very date that Dr. Gilland was installed, in
absentia, as President of the South Carolina Medical Association.

Dr. Gilland is a close personal friend of mine and it is he who is responsible for my involvement in
the SCMA. As a young physician in Conway, South Carolina, I admitted a patient with Hodgkin’s
Disease to the Conway Hospital. He stayed three days and I billed the insurance company and was
reimbursed for a history and physical and follow-up visits for a total of $35. Six months later,
however, I received a letter from the carrier stating the admission had been denied and I must
refund the $35 or it would be deducted from my next check. I was furious. I knew Dr. Gilland was
President-elect of the South Carolina Medical Association so I went to him and complained. I asked
him what he (the SCMA) was going to do about this injustice. Dr. Gilland, in his wisdom, said.
“Son, if you don’t like the system then why don’t you do something about it. I’m forming an
Insurance Peer Review Committee and I’ll put you on the committee where you can work to
improve the system.”

I learned something from Dr. Gilland that day which many physicians in this state need to learn.
First, if we have a problem in medicine then we need someone to go to with that problem. We need a
voice to speak for us. That voice in South Carolina is the South Carolina Medical Association and in
the nation it is the AMA. Second, we should become involved in trying to improve the health care of
the people of this country and the system in which we work. We need to follow Dr. Gilland’s
example and try to get all physicians to accept their responsibilities as MDs. We should not just take
from the system but become involved and give something back to medicine. I became personally
involved when Dr. Gilland gave me his wise advice. I served on that committee and later became its
Chairman. The committee members learned that some of the reviewers for the insurance com-
panies were denying claims inappropriately and we worked to improve the quality of the reviewers.
We developed a working relationship with the carrier and helped develop policies which were
beneficial to both the physicians and the carrier. We also found that insurance carriers had a right to
complain about a few physicians who were over-utilizing services and we worked to try to improve
that situation. As I mentioned in my Inaugural Address, I intend to reactivate that committee and I
have asked Charlie Sasser to chair it.

262

The Journal of the South Carolina Medical Association

^ Journal

'OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

VOLUME 85

JUNE 1989

NUMBER 6

TRENDS IN CARDIOVASCULAR MORTALITY
AND RISK FACTOR LEVELS
IN SOUTH CAROLINA:

SIGNIFICANCE FOR PREVENTION*

CARLTON A. HORNUNG, Ph.D., M.P.H.

ERNEST P. McCUTCHEON, M.D.

The overall decrease in the death rate from
cardiovascular disease (CVD) in the U.S. since
1950 is striking. This trend is generally recog-
nized, but important differences within subsets
of the U.S. population have received less rec-
ognition. Analysis and review of data for sub-
groups of the population can help develop
more appropriate interventions at national,
state and local levels. In this report, we high-
light some of the additional information and
illustrate its use to support the intervention
process at the state level.

DATA SOURCES AND METHODS

The data were provided by the S.C. Depart-
ment of Health and Environmental Control,
from its Office of Vital Records and Public
Health Statistics and from the Center for
Health Promotion. Projections of future mor-
tality trends were made by the straight line
method.

* From the Department of Preventive Medicine and Com-
munity Health, University of South Carolina School of
Medicine, Columbia, S.C. 29208.

RESULTS

THE DECLINE IN CVD MORTALITY
RATES IN THE U.S. AND
IN SOUTH CAROLINA

As shown in Figure 1, the decrease in mor-
tality has not been constant or uniform for all
types of CVD. Between 1970 and 1982, coro-
nary heart disease as a percent of total deaths in
the U.S., declined from 35 to 28 percent, a 20
percent decrease, while stroke mortality in the
same period decreased from 1 1 to 8 percent of
total deaths, a 27 percent drop. Even greater
variability exists for the changes within the 50
states. For South Carolina, mortality rates for
CVD have declined but continue to exceed
those of many other states. In 1968, S.C.
ranked third in crude CVD death rates for the
total population in the 35 to 74 age range. By
1978, S.C. ranked first, having the highest
crude mortality rate for CVD of the 50 states
despite the improved experiences shown
above for coronary and stroke related
mortality.

Significant variability also exists for the ef-
fects of the age, race, and gender distributions
in the population. After adjustment for the age

June 1989

267

CARDIOVASCULAR MORTALITY

Percent Decrease in Age-adjusted Death Rates
for Cardiovascular and Noncardiovascular Diseases

FIGURE 1. Percent Decrease in Age Adjusted Death Rates for Cardiovascular and Noncardiovascular Diseases in the
United States, 1968-1982.

distribution within the U.S., rates for race and
gender continue to show excessive mortality
from CVD in S.C. For the 1 970 to 1985 period,
adjusted mortality rates are higher in males
than in females and higher in nonwhites than
whites.

In 1970, the age adjusted death rate among
S.C. nonwhite males of 653 per 100,000 was 32
percent higher than the U.S. nonwhite rate
(Figure 2B). By 1986 the nonwhite male rate
had declined to 428 per 100,000 in S.C., but
was still 24 percent higher than the U.S. rate.
South Carolina white males in 1970 died at an
age-adjusted rate of 522 per 100,000 compared
to a U.S. rate of 441 per 100,000. Note that the
white male rate is 22 percent lower than the
nonwhite rate. By 1986, the S.C. white male
rate declined to 310 per 100,000 but continued
to be well above the U.S. average of 293 per
100,000.

The relationships for females are similar to
those for males (Figures 2C and 2D). The ad-
justed rate for S.C. nonwhite females was 438
per 100,000 in 1970, declining to 283 per
100,000 in 1986. The rates for the same years
among white females were 253 and 158 per

100,000 respectively.

The decline in the S.C. age-adjusted mor-
tality rates exceeds that of the U.S. as a whole
for each race-gender group except nonwhite
females. Between 1970 and 1984 the rate for
nonwhite males declined in S.C. by 36 percent
compared to a 31 percent decline nationally.
For white males the decline was 36 percent in
S.C. and 32 percent across the U.S., while the
rate for white females declined 34 percent for
S.C. and 33 percent for the nation. For non-
white females, the 37 percent decline for S.C.
was approximately equal to the national fig-
ures. More recent data for the years through
1986 show a three percent increase since 1984
in the S.C. nonwhite female mortality rate (i.e.,
from 275 to 284 per 100,000).

The percent decline in mortality from ische-
mic heart disease (ICD 410-414) has been
larger than the percent decline from other car-
diovascular diseases. Table 1 shows the per-
cent decline in mortality from ischemic heart
disease compared to all other causes of CVD
mortality.

Age-adjusted mortality from ischemic heart
disease declined by nearly 58 percent among

268

The Journal of the South Carolina Medical Association

CARDIOVASCULAR MORTALITY

FIGURE 2. Age Adjusted Race and Sex Specific Death Rates from Major Cardiovascular Diseases in the United States and
South Carolina, 1970-1985.

Age Adjusted Death Rates From
Major Cardiovascular Diseases (ICD 390-448)* In White Males

U.S. and South Carolina 1970-1985
(1940 Census Standard)

Age Adjusted Death Rates From

Major Cardiovascular Diseases (ICD 390-448) For Nonwhite Males

U.S. and South Carolina 1970-1985

—i 1 1 1 1 1 i 1 1

1970 1972 1974 1976 1978 1980 1982 1984 1986

A. White Males

B. Non white Males

Age Adjusted Death Rates From

Major Cardiovascular Diseases (ICD 390-448) For White Females

U.S. and South Carolina 1970-1985
(1940 Census Standard)

C. White Females

Age Adjusted Death Rates From

Major Cardiovascular Diseases (ICD390-448) For Nonwhite Females

U.S. and South Carolina 1970-1985
(1940 Census Standard)

S.C. nonwhite women between 1970 and 1985
compared to a 16 percent decline in mortality
from the remaining types of CVD. The de-
clines for the other race-gender groups were
about 10 percent less for ischemic heart dis-
ease, while mortality from other car-
diovascular diseases declined by about 18
percent. In other words, about 80 percent or
more of the total decline in CVD mortality
rates in South Carolina has been due to the
decline in mortality from ischemic heart
disease.

Although S.C. has made some progress over
the past 1 5 years and has kept pace with the rest
of the nation for all but nonwhite females, S.C.
rates continue to be considerably higher than
the U.S. average. In fact, these results show
that, relative to the rest of the nation, S.C. has
made very little real progress in reducing its
excess CVD mortality. If the average rates of
decline observed nationally and in S.C. for
each race-sex group are held constant and proj-

ected into the future, the number of years to
when rates in S.C. will equal the national aver-
age can be estimated. For white males in S.C.,

TABLE 1

Percent Decline in Age Adjusted Race and Sex
Specific Death Rates from Major Cardiovascular
Diseases, Ischemic Heart Disease and Nonischemic Heart
Disease in South Carolina, 1970-1985

Major

Cardiovascular

1HD

Non IHD
ICD 890-409

Attributable

ICD 190-448 ICD 410-414

415-448

to IHD

White Male

38.4

46.7

18.3

86.1

White Female

37.9

49.4

18.2

81.8

Nonwhite

Male

33.6

49.8

16.2

77.0

Nonwhite

Female

38.1

57.6

16.1

80.2

1. Direct Standardization, 1940 U.S. Census Standard.

2. 8th Revision 1970-78, 9th Revision 1979-85.

June 1989

269

CARDIOVASCULAR MORTALITY

the time projected to reach the national rate is
about 43 years.

Other race-sex groups may well take even
longer to reach parity. The time required for
nonwhite males to catch up is approximately
66 years, and for white females it is 34 years.
For nonwhite females the future appears to be
particularly bleak since the national rate is
declining at a faster rate than that observed in
S.C. As a result, the data for this group of South
Carolinians become relatively worse over fu-
ture years.

SOURCES OF THE DECLINE IN
CVD MORTALITY

The observed declines in CVD death rates
can be attributed to the two principal activities
of primary and secondary prevention.1 Pri-
mary prevention to decrease the incidence of
CVD has its greatest impact through reduction
of smoking, better control of hypertension, and
dietary changes that result in less consumption
of saturated fat and cholesterol. Secondary pre-
vention activities decrease the case fatality rate
among patients with CVD. Examples of sec-
ondary prevention, directed at individuals
with disease, include coronary care units, new
drug therapies for management of myocardial
ischemia and arrhythmias, and the application
of advanced technologies such as percutaneous
transluminal coronary angioplasty and coro-
nary artery bypass surgery.

Analyses of the relative contributions of pri-
mary and secondary prevention to the decline
in U.S. coronary heart disease mortality for the
years 1968-1976 indicate that approximately
70 percent of the decline is attributable to pri-
mary prevention activities and the remaining
30 percent of the decline results from interven-
tions based upon high technology and second-
ary prevention.1 Declines since 1976 have not
materially altered this conclusion.

RISK FACTOR LEVELS IN
SOUTH CAROLINA

The Behavioral Risk Factor Survey con-
ducted yearly as a joint effort of the Centers for
Disease Control and the S.C. Department of
Health and Environmental Control, has
shown the high prevalence of primary risk fac-
tors for CVD in S.C. (Table 2). Obesity levels

TABLE 2

Prevalence of Behavioral Risk Factors for
Cardiovascular Disease in South Carolina, 1986

Over

Sedentary

Current

Binge

Weight

Lifestyle

Smoker

Drinking

White Male

26.5

61 A

27.2

12.4

White Female

18.1

63.4

27.1

2.5

Nonwhite Male
Nonwhite

21.5

67.9

33.8

10.7

Female

36.5

70.7

17.0

1.9

are high, with over one-third of nonwhite
females more than 20 percent above their most
desirable weight, and about one in four white
males and one in five white females and non-
white males reporting excessive weight. Exces-
sive weight is associated with a lack of physical
activity. For nonwhite females, seven in 10
stated they have a sedentary lifestyle with in-
sufficient exercise and only about one third of
the total population exercises three or more
times per week.

Cigarette smoking has declined in South
Carolina as elsewhere, but 27 percent of whites
are current cigarette smokers. However, 34
percent of nonwhite males and 17 percent of
nonwhite females continue to smoke. Binge
drinking, defined as consuming five or more
alcoholic beverages in a 24-hour period, is a
risk factor for cardiac arrhythmia and sudden
death. Binge drinking is slightly more preva-
lent in white males than nonwhite males, but
about five times more prevalent in males than
females.

DISCUSSION & RECOMMENDATIONS

South Carolina, with its excess CVD mor-
tality, can clearly benefit from prevention ac-
tivities aimed at reducing the risk of CVD. The
high prevalence of known, modifiable CVD
risk factors in S. C. implies that primary pre-
vention activities have the potential to signifi-
cantly reduce mortality and morbidity. Such
prevention activities appear to be crucial for
eliminating S.C.’s excess mortality.

In addition to personal health behavior
changes by individuals, group influences are
important. Legislative bodies, businesses and
industries, and civic organizations can encour-

270

The Journal of the South Carolina Medical Association

CARDIOVASCULAR MORTALITY

age and promote behavior change for risk fac-
tor reduction. New and expanded health
education programs should be implemented in
elementary and secondary schools where true
primary prevention can have its maximum
effect. These programs should include infor-
mation about the positive benefits of regular
exercise and good nutrition and the adverse
consequences of poor dietary habits, lack of
exercise, smoking and other addictive behav-
ior. At the same time, school and industrial
cafeterias should be strongly discouraged from
serving only lunches that are high in saturated
fat and cholesterol. Popularity of such lunches
does not justify the omission of healthy alter-
natives. Similarly, restaurants ought to be
mandated to provide no-smoking sections and
be encouraged to offer broader menu choices
such as skim milk, baked and broiled meats,
spreads and dressings which are low in satu-
rated fat, and other “Heart Healthy” alterna-
tives.

Risk factor screening programs that are care-
fully administered to insure scientifically accu-
rate evaluations coupled with risk factor
counseling and educational materials should
be encouraged. Quality screening programs
can accomplish two objectives. First, they pro-

vide community education on the risks for
cardiovascular disease. Second, they alert indi-
viduals to their own personal risks of car-
diovascular disease and what they themselves
can do to reduce that risk.

Finally, physicians can emphasize preven-
tion activities in their routine care of patients
and, when management beyond that available
in their practice is needed, refer those patients
for diet instruction, weight control, smoking
cessation or to learn other special skills in risk
factor modification. When physicians give
greater emphasis to prevention activities in
their role as community leaders and in the care
of patients, South Carolina’s record of excess
deaths from cardiovascular disease can be re-
duced. □

REFERENCE

1. Goldman L, Cook EF: The decline in ischemic heart
disease mortality rates. An analysis of the comparative
effects of medical interventions and changes in lifestyle.
Ann Int Med 101:825-836, 1984.

ACKNOWLEDGEMENT

The authors gratefully acknowledge the support of the
staff of the S. C. Department of Health and Environmental
Control, particularly those in the Office of Vital Records
and Public Health Statistics, Division of Biostatistics
(Linda Jacobs) and the Center for Health Promotion (Dan
Lackland), who acquired the data and made it available to
the authors.

June 1989

271

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MEETING

ANNOUNCEMENT

South Carolina Chapter
American Academy of Pediatrics
Annual Scientific Session

“Pediatric Update”

Faculty: Frank A. Oski. M.D., Heinz F.
Eichenwald, M.D., William B. Strong.
M.D.

Meeting Site: The Grove Park Inn.
Asheville, North Carolina

Meeting Dates: Thursday. August
3-Sunday, August 6, 1989

Credit: AMA Category I and PREP. 6
hours.

For more information contact: Debbie Shealy, SC
Chapter AAP, P.O. Box 11188, Columbia, SC
29211, (803) 798-6207.

272

The Journal of the South Carolina Medical Association

ADVANCES IN THE TREATMENT OF
SUPRAVENTRICULAR TACHYCARDIA*

PAUL C. GILLETTE, M.D.**
FRED A. CRAWFORD, M.D.
DEREK A. FYFE, M.D.
ASHBY B. TAYLOR, M.D.
HENRY B. WILES, M.D.

Supraventricular tachycardia is defined as
an abnormally fast heart rate originating above
the bifurcation of the bundle of His. It is the
most common abnormal rhythm in children
and young adults. Supraventricular tachycar-
dia may be due to reentry or automaticity in
either normal or abnormal cardiac structures.
The mechanism of supraventricular tachycar-
dia dictates the treatment.

The treatment of supraventricular tachycar-
dia has changed in the last five years due to a
better understanding of its mechanisms, new
drugs, surgical techniques, and new electrical
techniques. The treatment of supraventricular
tachycardia may be considered as primary, sec-
ondary, and tertiary.

PRIMARY TREATMENT OF SVT

Primary treatment of SVT consists of stop-
ping the first episode or a subsequent episode.
When considering the primary treatment of
SVT, it must be remembered that SVT is rarely
fatal. On the other hand, prolonged episodes
can lead to congestive heart failure. Therefore,
the primary treatment of SVT should be
prompt, but not radical.

The mainstays of primary treatment of SVT
in children and adults are vagal reflexes. In
young children, the first treatment is the “div-
ing reflex.” This involves application of cold to
the facial region which leads to a reflex which
may interrupt reentry circuits involving the

* From the Divisions of Pediatric Cardiology (Dr.
Gillette, Fyfe, Taylor, and Wiles) and Cardiothoracic
Surgery (Dr. Crawford), Medical University of South
Carolina, Charleston, S. C.

** Address correspondence to Dr. Gillette at the Division
of Pediatric Cardiology, Medical University of South
Carolina, 171 Ashley Avenue, Charleston, S. C. 29425-
0682.

AV node or SA node. Vagal reflexes may tem-
porarily slow an automatic focus or create sec-
ond degree AV block in response to an auto-
matic focus, atrial flutter, or fibrillation. The
standard vagal reflexes, such as carotid sinus
pressure, rarely work in the infant, but become
more useful in older children and adolescents.
Eyeball pressure is effective, but probably
shouldn’t be used because of the possibility of
retinal detachment. Vomiting also causes a
vagal reflex and often leads to a cessation of
SVT. Drugs, such as neosynephrine, may be
used to enhance vagal tone by increasing sys-
temic arterial pressure. Tensilon enhances the
effect of acetylcholine.

If vagal maneuvers fail, the next therapy
may be either pharmacological or electrical.
Since atrioventricular node and sinus node
cells are based on a calcium action potential
blocking calcium channels is frequently effec-
tive if either of the nodes are involved in a
reentry circuit. Verapamil is the calcium block-
ing agent which has the most effect on the AV
node. The majority of SVTs are due to reentry
circuits involving the AV node. Thus, intra-
venous verapamil 0. 1 5 mg/kg over three min-
utes (max dose 5 mg) is very effective in
converting SVTs. Infants under one year of
age, however, seem to be more sensitive to the
negative inotropic and chronotropic effects of
verapamil, and our policy is not to use ve-
rapamil in these infants.

An alternative to verapamil is the use of
transesophageal overdrive pacing. Reentry cir-
cuits including atrial flutter are susceptible to
conversion, if the circuit can be captured by
rapid atrial pacing. A small percentage of pa-
tients will convert to atrial fibrillation, but
unless they have Wolff-Parkinson-White syn-

June 1989

275

SUPRAVENTRICULAR TACHYCARDIA

TABLE I

Primary Conversion Techniques

I. Vagal reflexes

a) diving reflex

b) carotid sinus compressure

c) neosynephrine or tensilon

II. Verapamil (if over one year of age)

III. Esophageal overdrive pacing

IV. Synchronized DC cardioversion

drome, the ventricular rate will usually be less
than the SVT rate. Many of them will shortly
convert to sinus rhythm. The use of overdrive
pacing is particularly useful in patients with
the bradycardia-tachycardia syndrome since
pharmacologic or reflex conversion may result
in severe bradycardia. Verapamil is particu-
larly likely to cause bradycardia in patients
with sick sinus syndrome or in patients who
have received a B-blocker such as propranolol.

Other intravenous drugs, such as digoxin,
propranolol or procainamide may convert
SVTs. The action of digoxin, however, is slow
and it may increase the risk of complications if
DC cardioversion becomes necessary of if the
patient develops Wolff-Parkinson- White. Pro-
pranolol and procainamide may cause signifi-
cant bradycardia and/or hypotension, particu-
larly if they fail to convert the SVT. Therefore,
we recommend the use of synchronized DC
cardioversion when reflexes, verapamil, and
overdrive fail. Newer defibrillators have accu-
rate synchronization and documentation at
the time of discharge. The availability of pads
connected directly to the defibrillator have im-
proved the efficiency of cardioversion. The
pads are applied to the anterior and posterior
chest. Only XU to Vi joule/kg is required to
convert most SVTs. Ketamine is a safe and
effective form of sedation for cardioversion. It
increases blood pressure and maintains respi-
ratory effort. It may, however, increase the
tachycardia rate before cardioversion.

SECONDARY TREATMENT OF SVT

The secondary treatment of SVT aims to
prevent recurrences of the SVT. Some patients

TABLE II

Doses of Primary Conversion Techniques

Verapamil — 0. 1 5 mg/kg IV over three minutes
(may repeat once)

Neosynephrine — 0.01 to 0.1 mg/kg IV bolus
(increase dose progressively
until systolic BP>200
mmHg)

Tensilon — 0.1 mg/kg intravenously

do not require chronic treatment if their SVTs
are relatively slow or infrequent. All infants
and young children should be treated since
they may slip into congestive heart failure be-
fore the tachycardia is noticed.

Digoxin is the most frequently used drug for
prevention of SVT. It slows conduction in the
AV node and probably prevents some pre-
mature beats that initiate SVT. In addition to
attempting to prevent SVT, digoxin slows the
rate of SVT, if it does occur and supports the
myocardium. Digoxin is contraindicated in
patients with Wolff-Parkinson-White syn-
drome because it may increase conduction ve-
locity in some accessory connections. Thus, it
may increase the tachycardia rate or the ven-
tricular response to atrial fibrillation. Oral beta
blockers may prevent episodes of SVT. Newer
beta-blockers may be used once a day, thus
decreasing the burden of more frequent dosing.
Oral verapamil is another safe and frequently
effective drug for the prevention of SVT. Ve-
rapamil has a low incidence of side effects.
Type I drugs, such as quinidine, procainamide
or dysopyramide may prevent SVT, but carry
the risk of serious side effects or death. These
drugs also have unpleasant gastrointestinal
and urinary tract side effects. Type IC drugs
such as flecainide are very effective in prevent-
ing SVT with a low incidence of side effects.

Young children frequently outgrow their
SVT. Thus, if there are no episodes for one or
two years during treatment, a trial without
drugs is warranted. Even patients with WPW
syndrome may experience long tachycardia
free periods. This is especially true between the
ages of one and 10 years.

276

The Journal of the South Carolina Medical Association

SUPRAVENTRICULAR TACHYCARDIA

TABLE III

Pharmacologic Prevention of SVT

Digoxin — 10 mcg/kg/day up to 0.5 mg/day
lower doses for prematures or
neonates

Propranolol — 2-8 mg/kg/day up to 80 mg q 6h
Atenolol — 1 mg/kg/day in one dose
Verapamil — 3-5 mg/kg/day in three doses

TERTIARY TREATMENT OF SVT

Although significant advances have been
made in the primary and secondary treatment
of SVT, the most important advances have
been made in the tertiary treatment of SVT.
Tertiary treatment begins when two drugs
have been tried at adequate doses or serum
concentrations and the patient is either still
having important episodes of SVT or having
side effects from the drugs.

Tertiary treatment of SVT is dependent on a
knowledge of the exact mechanism. Although
the exact mechanism can be estimated based
on the surface ECG, it requires detailed elec-
trophysiological study for exact delineation.
Greater than 90% of SVTs are due to reentry.
Nearly 50% involve reentry using an accessory
connection (Kent bundle). Many are due to
reentry within the AV node. Only a small per-
centage are due to an automatic focus within
the atrium or bundle of His.

AUTOMATIC FOCUS TACHYCARDIA

Automatic focus tachycardias may originate
in the atrium or bundle of His. They are
chronic and usually persistent tachycardias
which are unresponsive to all usual treatments
including overdrive pacing and DC cardio-
version.

Junctional (His bundle) automatic tachycar-
dia is very rare. It is a congenital tachycardia
which results in severe congestive heart failure
and death in 50% of patients. We have recently
proposed destruction of the bundle of His and
implantation of a pacemaker as treatment for
this form of SVT.

Atrial automatic tachycardia is less life
threatening, but has been shown to lead to a
congestive cardiomyopathy after years of ta-
chycardia. Since this tachycardia is resistant to

all standard forms of medical treatment, we
have used catheter electrical ablation, surgical
cryoablation, or removal of the focus. The car-
diomyopathy has resolved in each case once
the tachycardia was stopped.

REENTRY TACHYCARDIAS

Reentry tachycardias involving reentry
using a Kent bundle or rapid ventricular re-
sponses to atrial flutter or fibrillation can be
successfully treated by surgical division of
cryoablation of the Kent bundle. This pro-
cedure involves use of the heart-lung machine,
but the complication rate is exceedingly low,
and the success rate is greater than 90%. Re-
producible success in catheter ablation of Kent
bundles has not yet been reported. We and
others have used surgical Kent bundle ablation
in patients with WPW syndrome who have
symptomatic tachycardias requiring more
than one drug for control or who have signifi-
cant side effects from drugs. Surgical treatment
is particularly attractive in young patients
whose life is frequently severely altered by epi-
sodes of SVT and in patients in whom taking
the drugs cause psychological problems.

One third of the patients with a Kent bundle
do not have WPW syndrome on ECG because
the Kent bundle cannot conduct antegrade.
These patients are detected by detailed electro-
physiological studies of their supraventricular
tachycardia. Surgery is equally effective in
these patients.

It is currently possible to reproducibly alter
AV node physiology by surgery thus prevent-
ing SVT without the risk of complete AV
block. In the rare patient whose symptoms
warrant the production of AV block, it can be
performed by catheter ablation. Patients with
AV node reentry or atrial flutter may also be
treated by implantation of an automatic over-
drive pacemaker which stops the tachycardia
after two to three seconds. These pacemakers
are not appropriate for patients with WPW
syndrome because of the possibility of induc-
tion of atrial fibrillation. Newer automatic
antitachycardia pacemakers can successfully
differentiate sinus tachycardia from parox-
ysmal tachycardia using the abruptness or the
onset of tachycardia. They are particularly
useful in children with bradycardia as well as
tachycardia.

June 1989

277

SUPRAVENTRICULAR TACHYCARDIA

TABLE V

Tertiary Treatment of SVT

Drugs
Pacemakers
Catheter Ablation
Surgical Ablation

The selection of a tertiary treatment of SVT
must take into account not only the mecha-
nism of the tachycardia, success and complica-
tion rates of the treatment, but also the
emotional needs of patients to be as nearly
normal as possible.

SUMMARY

Patients with supraventricular tachycardia
should be able to lead a perfectly normal life
without significant treatment related side ef-
fects. Many of these patients have normal

hearts and no other significant medical prob-
lems. Using the techniques described above,
no patient should have significant symptoms
from SVT. □

REFERENCES

1. Gillette PC: The mechanisms of supraventricular ta-
chycardia in children. Circulation 54:133, 1976.

2. Gillette PC, Garson A Jr: Electrophysiologic and phar-
macologic characteristics of automatic ectopic atrial
tachycardia. Circulation 56:571, 1977.

3. Garson A Jr, Gillette PC: Junctional ectopic tachycar-
dia in children: electrocardiography, electrophysiology
and pharmacologic response. Am J Cardiol 44:298.
1979.

4. Orzan F, Gillette PC: Reciprocating tachycardia due to
a right-sided unidirectional retrograde anomalous path-
way. PACE 1:306, 1978.

5. Wu D, Amat-y-Leon F, Simpson RJ, Latif P. Wyndham
CRC, Denes P, Rosen KM: Electrophysiologic studies
with multiple drugs in patients with atrioventricular
reentrant tachycardias utilizing an extranodal pathway.
Circulation 56:727, 1977.

6. Wu D, Wyndham CRC, Amat-y-Leon F, Miller R,
Dhingra RC, Rosen KM: Chronic electrophysiological
study in patients with recurrent paroxysmal tachycar-
dia: a new method for developing successful oral anti-
arrhythmic therapy. In, Reentrant arrhythmia-Mecha-
nisms and Therapy (Kulbertus H, ed), Lancaster,
England, MIP Press, 1977.

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278

The Journal of the South Carolina Medical Association

NEWSLETTER

JUNE 1989

HIGHLIGHTS OF MAY 25 BOARD OF TRUSTEES MEETING

The Board heard a report on a special committee being formed by
Senator Hugh Leatherman to study the cost of health care at the
state level, particularly with regard to insurance for small
business employers. Because Medicare is a major problem in the
cost of health care, SCMA President Dan Brake will communicate
with Senator Leatherman to urge Medicare representation on the
committee .

In an effort to assist Blue Cross and Blue Shield in convincing
HCFA to implement a policy of equal reimbursement for equal
services in the Medicare program, the Board reaffirmed a 1984
SCMA policy statement "opposing the UCR reimbursement system in
its current form because it is discriminatory against patients
and physicians alike, and the SCMA supports equal reimbursement
by third party payors for equal services, with no mandatory
assignment, the freedom to balance bill, and an upgrade of
reimbursement schedules every six months." See the "President's
Page" in this issue of The Journal for additional information.

President-elect John Simmons reported on the SCMA successes in
the current legislative session, noting that none of the bills
opposed by the SCMA were passed, and all bills supported by the
SCMA either were enacted or narrowly missed being enacted.

The Board commended Swift C. Black, MD, for his many years of
service as Sergeant-At-Arms at SCMA Annual Meetings.

Approved by the Board was a resolution to submit to the AMA House
of Delegates requesting "immediate action by HCFA and, if
necessary, by Congress to withdraw the requirement for inclusion
of the referring physician's ID number on Medicare claims of
radiologists, pathologists, independent laboratories and other
physicians when a patient was referred by another physician for
consultation or treatment."

In addition, an SCMA resolution will be submitted to the AMA
House of Delegates requesting that "the AMA examine the
subsequent acts of Congress and regulations promulgated by the
governmental agencies under these laws which impose onerous

burdens on physicians in the care of Medicare patients, to
determine whether such acts or regulations are in violation of
Section 1801 of PL 89-97, and ... that the AMA take whatever
legal action that is feasible to prevent implementation and/or
enforcement of laws or regulations which are in conflict with
Section 1801 of PL 89-97."

The Board voted to ask the Editorial Board of The Journal to
begin compiling historical data on SCMA past presidents for use
by medical historians in the future.

With regret, the Board accepted the resignation of D. Strother
Pope, MD, as director of the Doctor of the Day program in the
state legislature, and commended Dr. Pope on his excellent work
and years of service to this effort. A Doctor of the Day
Committee of the SCMA will be appointed to continue Dr. Pope's
work.

The Board agreed that the SCMA Hospital Medical Staff Section
would meet at breakfast during the ninth annual Conference for
Trustees, Administrators and Physicians to be held September 21-
23, 1989 at the Mariner's Inn, Hilton Head Island, SC.

SCMA Board members agreed to write the SC Congressional
Delegation opposing (1) expenditure targets, (2) the ban on
physician referrals (HR 939) and (3) disproportionate cuts in
Medicare Part B.

MEDICARE UPDATE

Consultation Services

As mentioned in last month's Newsletter, all claims for
consultation services (CPT-4 codes 90600 through 90654) rendered
on or after June 1, 1989 must include the referring physician's
name, identification number and two-letter abbreviation for the
state where services were rendered. This information should be
put in block #19 of the HCFA-1500 claim form. Physicians who do
not file claims for their patients must include this information
on the itemized bill given to the patient for filing purposes.
For more detailed information regarding referring and ordering
physician data, refer to recent Medicare Advisories from Blue
Cross and Blue Shield.

Medicare Fraud and Abuse Act

Physician joint ventures when involving the care and treatment of
the Medicare patient, are coming under closer scrutiny from the
federal government under the Medicare Fraud & Abuse Act (42
U.S.C. 1320a-7 (b) (b) , 1128B(b) of the Social Security Act). The
Act prohibits any person from receiving any remuneration,
overtly or covertly, in exchange for a referral of health care
services covered under Medicare and Medicaid. Criminal penalties

of imprisonment up to five years and fines up to $2 5,000 are
possible for willful offenses.

Proposed regulations published in March in the Federal Register
outlined nine "safe harbors," different tests which can be
applied to a business situation in the health care services area.
If the criteria of a "safe harbor" are met by a health care
business venture, the arrangement will be deemed acceptable to
the federal government. The nine safe harbors involve the areas
of (1) investment interest; (2) space and equipment rental; (3)
personal service of management controls; (4) sale of a physician
practice; (5) referral services; (6) warranties; (7) discounts;
(8) employees; and (9) group purchasing organizations.

For a copy of the proposed regulations which include the criteria
of each of the nine "safe harbors," contact Barbara Whittaker at
the SCMA .

MEDICAID UPDATE

Sterilization Claims: Effective January 1, 1989, only the
Sterilization Consent Form (HHSFC 1723) is required to process a
sterilization claim.

Breast Reconstructive Surgery; Effective with dates of service
on March 1, 1989, the Medicaid program will consider the
expenditure of funds for reconstructive breast surgery following
a mastectomy due to carcinoma of the breast, but prior
authorization is required and approval will be based on specific
criteria for medical necessity.

Coding Updates for ER and Special Services; Medicaid is now
following Medicare's updated policy for use of the unusual or
special services codes listed in the "Special Services and
Reports" section of the CPT-4 coding manual. For these coding
updates, see the Medicaid Bulletin dated April 12, 1989.

Expanded Medicaid Services; With the passage of the Medicare
Catastrophic Coverage Act in 1988, states are required to cover
a new group of individuals for Medicare premiums and cost
sharing. This group of individuals is known as Qualified
Medicare Beneficiaries (QMB) . QMBs must be entitled to part A
hospital insurance, have income below the federal poverty level
and have resources below twice the SSI limit. Effective February
1, 1989, Medicaid began covering the Medicare premiums, the
coinsurance and deductibles for all Medicare covered services and
the regular Medicaid services.

Effective April 1, 1989, Medicaid coverage was expanded to cover
children up to age six (6) in families with income under 100
percent of the federal poverty level. Also, the income
eligibility level for pregnant women and infants expanded from
100 percent to 125 percent of the federal poverty level. This
percentage may increase to 150 percent later this calendar year.

PRO UPDATE

CMR Review Procedures and Criteria Updated

Carolina Medical Review (CMR) has updated its Procedure and
Review Criteria Manuals. These manuals assist CMR's non-
physician reviewers in screening medical records. Physician
consultants do not use these manuals in making determinations;
instead, they use their medical judgment and expertise.

Hospitals received copies of updated criteria in PRO Bulletin 89-
5. Major changes of interest to physicians include:

* the addition of criteria for some procedures, such as
appendectomy, laparoscopy and circumcision;

* changes in preprocedure review criteria for transurethral
resection of prostate, lens procedures and inguinal hernia; and

* the addition of a section on ambulatory care and
documentation standards.

Updated copies can be obtained by calling CMR's Public Relations
Coordinator, Melinda McDonald at 1-800-922-3089 or 803-731-8225.

PRO Update on Short Stay Policy

Carolina Medical Review (CMR) requests that if a physician has
reason to expect a patient will remain in the hospital 24 hours
or less, then the patient should be admitted for observation.
Hospital billing departments should be notified, preferably by
admission orders, of the intent of the admission for observation
to ensure the patient is billed under Part B of the Medicare
program. If the hospital is not informed of the reason for
observation and bills the patient under Part A, then this case is
subject to review by CMR. These admissions are often denied
because the case fits the observation category (Part B) , but was
billed as a full admission (Part A and DRG) . Therefore, it is
important that physicians specify the reasons for admission with
the hospital within 24 hours of admitting a patient.

CMR would also like to remind physicians of the following:

1. The 24-hour observation clock does not stop at 24 hours.
Observation status has no time limit.

2. CMR does not review cases which are properly billed by
the hospital as observation services (Part B) . The PRO only
reviews hospital admissions billed under Part A.

3. CMR is not focusing its review on short stays.

4. Observation status can be upgraded to full admissions at
any time the physician deems the stay will be extended beyond 24
hours and acute care services are necessary.

Physician Documentation: The "Importance of Documentation in PRO
Review” is a brief summary of necessary physician documentation.
Copies are available at your hospital, from the PRO, or by
contacting Barbara Whittaker at the SCMA.

STATE BOARD OF MEDICAL EXAMINERS: REREGISTRATION DEADLINE

July 1, 1989 is the deadline for physician reregistration with
the State Board of Medical Examiners. Physicians whose address
has changed since they last reregistered should notify the Board
in writing immediately.

ANTITRUST SCRUTINY OF PHYSICIANS

The US Justice Department is scrutinizing more and more
specialists in large cities and physicians in small towns
because, according to the chief of the antitrust division, when
they engage in anti-competitive activity they tend to strangle
health care delivery in their respective markets.

Edward B. Hirshfield, AMA's Associate General Council, advises,
however, that in forming a joint venture, if physicians are
proceeding in good faith, they will not be "put in jail." He
cites a few examples of activity which do or do not constitute
violations of antitrust law:

* If 10 independent physicians in a community of 100
physicians agree to charge $35 for an office visit, that
agreement constitutes a price-fixing arrangement and is a
criminal violation of antitrust law.

* If 10 physicians in a group practice agree to charge $35
for an office visit, this is not considered restraint of trade
because they are a single business entity and not competitors.

* It would be a criminal violation if two clinic
administrators in a city get together and agree that their
physicians will charge $35 for an office.

* If a medical society should advise its members they
should boycott an HMO, such activity would be considered a
criminal violation.

* If the same medical society should review an HMO contract
and explain its provisions to its members without making any
recommendation, this activity would be considered legal.

AMA PHYSICIAN NEGOTIATION ADVISORY OFFICE

The AMA has established a Physician Negotiation Advisory Office

to assist physicians in their relationships with third-party
payors. The Office will supply information to educate physicians
regarding the antitrust laws and will provide practical advice
for appropriate responses in most situations facing physicians
today. The Office will also refer physicians to health law
attorneys who can provide representation when necessary. For
more information contact Mr. Mike lie, AMA Office of the General
Counsel, at 312-645-5601.

MAXI CARE BANKRUPTCY

The Maxicare bankruptcy has caused confusion among many
physicians who are concerned about the obligations to Maxicare
pursuant to orders issued by the bankruptcy court, and whether
they will be paid for treating Maxicare patients. For a copy of
a memorandum setting forth commonly asked questions and answers
to them, call Kim Fox at SCMA headquarters.

RADIO PUBLIC SERVICE ANNOUNCEMENTS ON HEALTH HAZARDS OF TANNING

Three public service announcements are currently being
distributed to radio stations throughout the state warning
listeners of the health hazards relating to the sun and tanning
beds. The spots are spponsored by the SC Dermatological

Association and the SCMA.

AMA LEGISLATIVE ACTIVITIES

During the month of April 1989, the AMA submitted comments to the
Legislative and Executive Branches of the federal government
on the following subjects:

* Scheduling of anabolic steroids;

* Quality review and assurance in Medicare?

* Medicare and the FY 1990 Federal Budget?

* Funding for WHO and PAHO?

* Graduate medical education?

* Medicare - Physician payment reform?

* Automobile safety belts and motorcycle helmets?

* FDA funding;

* Medicare payment for teaching physicians and for
inpatient pathology services?

* Toy guns ;

* Modifying the PRO program?

* Medicare fee schedule for radiologist services;

* Additional PRO outpatient surgery generic quality
screens ; and

* Long term care.

IRS EMPLOYEE BENEFITS PROVISION ( Section 89^

Implementation of Section 89 of the Internal Revenue Service
Code, a provision of the 1986 tax law that forces businesses to
provide equal benefit packages to high and low-compensated
employees, will be effective October 1, 1989. The House Ways and
Means Committee is considering proposed changes which could
simplify Section 89 rules determining discriminatory practices.
Section 89 cannot be ignored without endangering the tax status
of all employee benefit plans (other than pension) . Contact your
accountant or attorney today.

FOSTER PARENTS NEEDED FOR CHILDREN WITH MEDICAL PROBLEMS

Foster parents are desperately needed to provide shelter and care
for children who have medical problems and who are on heart
monitors or have been diagnosed as having AIDS. Interested
families are urged to contact Bill Calliham, Richland County
Department of Social Services at 256-0770. Special training will
be provided for those who apply if needed.

PUBLICATIONS AVAILABLE

The SCMA has received a new issue packet on cholesterol,
developed by the Division of Communications of the AMA. Included
is background information and a typical food editor release with
recipes, a speech entitled "Cholesterol: (Some) Bad News and

(Mostly) Good News", and handouts for use during group
presentations. If you would like a copy of these materials for
possible use in your community, contact Melanie Kohn or Kim Fox
at SCMA headquarters.

The AIDS Guidelines for Health and Public Safety Workers
recently published by the Department of Health and Human
Services, is now available to physicians for a nominal charge.
This document outlines recommended procedures to be followed by
health care, law enforcement and public safety workers who may be
exposed to both HIV and HBV infection. To obtain a copy, at a
cost of approximately $10, call HHS in Baltimore at 301-966-7843.

The Surgeon General, the American Cancer Society and the National
Cancer Institute are asking physicians across the nation to urge
their patients who smoke to quit. A booklet, "Quit for Good: A

Practitioner's Stop Smoking Guide," is available. Also available
is a promotion kit including pamphlets for the office, a poster,
50 patient-doctor contracts to quit smoking, smoker ID stickers

for patient files, no smoking signs, etc. To order the booklet
and/or kit, write: NCI, Building 31, Room 10A24, Bethesda, MD
20892 or call 1-800-4-CANCER. You will need to let them know you
are a physician or health professional to obtain the information.

UPCOMING CONFERENCES

"Eliminating Risks in Emergency Rooms," sponsored by the SCMA,
SCHA, SC Society for Risk Management/Quality Assurance
Professionals, Midlands AHEC/Nursing Division and the Greenville
Hospital Systems, will be held on June 28, 1989 at the Embassy
Suites Hotel in Columbia. A registration fee of $20 covers the
cost of lunch, coffee breaks and other program expenses. For
additional information, contact Doris Clevenger, SCHA, PO Box
6009, West Columbia, SC 29171-6009.

The Third International Conference on AIDS Education, sponsored
by the International Society for AIDS Education, will be held
September 10-13, 1989 at the Stouffer Nashville Hotel and
Nashville Convention Center. For registration information,
contact the conference secretariat at Vanderbilt University,
Nashville, Tennessee 37232 or call 615-322-2437 or 615-322-2252.

The Third National Medical Staff Conference is scheduled for
October 19-21, 1989 in Washington, DC, for medical staff
officers, medical directors, CEOs and Board members. Topics to
be covered include antitrust, peer review, RBRVS , quality
assurance, ethics and indigent care. For more details, call
312-645-4761.

CAPSULES

Congratulations to James Lucas Walker, MD, of Clinton, SC,
chosen as the Physician of the Year for 1989 by the SC Academy of
Family Physicians.

SCMA NEWSLETTER
is a publication of the
South Carolina Medical Association.
Contributions welcomed.
Melanie Kohn, Editor
Joy Drennen, Assistant Editor
798-6207, in Columbia
1-800-327-1021, outside Columbia

DESCENDING THORACIC AORTA
TO FEMORAL ARTERY BYPASS*

R. RANDOLPH BRADHAM. M.D.**

P. REID LOCKLAIR, JR.. M.D.

ARTHUR GRIMBALL. M.D.

Bypassing obstructions in the infrarenal
aorta and iliac arteries is commonplace and
patency rates are highly satisfactory. However,
there is a small segment of this patient popula-
tion for which some procedure alternative to
the abdominal aorta femoral bypass is indi-
cated. Popular choices are the femoral to
femoral bypass for unilateral occlusion and the
axillofemoral bypass for unilateral or bilateral
occlusions.

In 1961. Blaisdell1 introduced another op-
tion with the descending thoracic aorta to
femoral artery bypass graft through an extra-
peritoneal route. His first case was done to
replace an infected abdominal aortic bifurca-
tion prosthesis. Subsequently, this procedure
has been adopted for expanded indications in-
cluding infected abdominal grafts, obstructed
abdominal prostheses, failed axillofemoral
grafts, hazardous or virtually impossible ab-
dominal operations, gross obesity, and for high
infrarenal aortic obstructions.

We have had two recent patients for whom
this operation was invaluable for re-
vascularization of the lower extremities.

CASE REPORTS

Patient 1: L. V. was a 60-year-old white
female who had claudication for two years in
both lower extremities. During the six months
before admission, her activity was severely
limited. Attempts at angiography in another
city failed because of the extent of her disease.
In our hospital these were finally accomplished
via an axillary approach. There was total occlu-
sion of the abdominal aorta at its bifurcation.
The occlusion extended into the iliac arteries.

* From the Departments of Surgery, Roper Hospital and
Saint Francis Xavier Hospital, Charleston, S. C.

** Address correspondence to Dr. Bradham at 315 Cal-
houn Street. Suite 405, Charleston, S. C. 29401.

FIGURE 1

There was satisfactory run-off bilaterally. (Fig.
1) An infrarenal aortobifemoral bypass was
attempted but aborted as the aorta was so cal-
cified that attempts to occlude it and sew a
graft to the tenuous adventitia was hazardous.
She was discharged to return for an ax-
illofemoral or thoracic aortofemoral graft.

One month later she was admitted to the
hospital for severe left foot pain. There was
anesthesia of the foot and limited motor func-
tion. The day of admission, a descending thor-
acic aortobifemoral graft was done.
Postoperatively, the pulses in both feet were
palpable. She recovered quickly and has re-
mained free of claudication.

Patient 2: J. L. was a 57-year-old white
female known to be hypertensive and a heavy
smoker. For the two years prior to admission,
she had progressive bilateral lower extremity

June 1989

283

THORACIC AORTA— FEMORAL BYPASS

claudication. Her femoral pulses were very
weak. Arteriography revealed extensive ather-
osclerosis involving the aorta and iliac arteries.
There was almost total occlusion of the left
common iliac artery at its origin with a rich
collateral flow supplying most of the blood
flow to the left leg. (Fig. 2)

FIGURE 2

Because of the severe and extensive disease,
decision was made to do a lower thoracic aorta
to bifemoral bypass graft. The lower thoracic
aorta proved to be essentially free of disease.
The femoral vessels were small with posterior
plaques but with adequate lumens. The patient
had bilateral pedal pulses postoperatively and
an uneventful course. She has continued to be
free of claudication and has unlimited walking
tolerance.

TECHNIQUE

The anesthesiologist intubates the patient
with a double lumen endotracheal tube so the
left lung can be collapsed for better exposure.
The patient is positioned with the left chest
elevated to 45 degrees and with the hips left
supine. (Fig. 3) The left chest, abdomen, and

FIGURE 3

groins are draped as a sterile field. The femoral
arteries are exposed through small groin inci-
sions, and the femoral arteries evaluated prior
to thoracotomy. An anterolateral seventh in-
tercostal space thoracotomy is done to expose
the distal descending thoracic aorta. The in-
ferior pulmonary ligament is transected and
the lung packed away superiorly. The lower
descending thoracic aorta is exposed by incis-
ing the overlying parietal pleura. A small seg-
ment of the aorta is partially mobilized with
care to protect the intercostal arteries. A woven
dacron bifurcated graft, usually a 16X8X8, is
preclotted and the patient is given heparin. A
partial occlusion clamp is placed on the aorta
and an aortotomy done. The aortic end of the
graft is then anastomosed to the aorta end to
side with a running 4-0 prolene suture at near
right angle. It is preferable to route the graft to
the groins through a preperitoneal approach.
This sometimes necessitates a small incision in
the left flank to facilitate passage of the graft
limbs to this position and, then, from this
position to the groins. When there is a lot of
scarring in this plane, a subcutaneous route can
be used. End to side anastomoses are made at
the appropriate angle between the distal graft
limbs and the femoral arteries with a 5-0 pro-
lene continuous suture. These anastomoses are
usually positioned at the take-off of the pro-
funda femoris artery. A single chest tube is
inserted.

DISCUSSION

The thoracic aorta to femoral artery bypass
graft is no panacea for revascularization of the

284

The Journal of the South Carolina Medical Association

— FEMORAL BYPASS

THORACIC AORTA

lower extremities. It is not the procedure to be
done in a debilitated patient or for someone
with severe pulmonary disease. For others,
with indications as listed in the introduction of
this paper, the procedure provides a patient
with an additional chance to gain satisfactory
lower extremity revascularization. In properly
selected patients, the procedure is associated
with low morbidity and mortality. McCarthy
and associates2 reported a series of 1 3 patients
with no operative mortality. Seven of their
patients had infected abdominal aortic grafts
removed and initially replaced with ax-
illofemoral prostheses. Five others had failure
of at least two aortofemoral grafts and one was
done in a patient after multiple complex ab-
dominal operations. .All of these grafts, except
one, were patent at 72 months.

Schultz, Sterpetti, and Feldhaus3 reviewed
their experience with reoperation for recurrent
obstruction occurring after aortoiliac or aor-
tofemoral reconstruction. A group of 15 pa-
tients (25 limbs) underwent retroperitoneal
descending thoracic aorta-femoral artery by-
pass and another group of seven patients ( 1 1
limbs) had axillofemoral bypass grafts. The
five-year actuarial patency rate was 80.2% for
the former and 32.9% for the latter.

Lakner and Lukacs4 found no evidence of
“steal effect” in the splanchnic circulation and
their review of the literature failed to disclose
any such cases.

The descending thoracic aorta represents an
excellent source of inflow and is seldomlv in-
volved with severe atheromata. Froysaker and
associates5 measured a flow of 1050 ml/min in
a patient with descending thoracic aor-
tobifemoral graft, and flows of 2000 and 840
ml/min in two patients with thoracic aortoiliac
grafts. .Although distal resistance, a major fac-
tor in the flow rate of a graft, varies in patients,
the above recorded flow rates are much better
than the mean flow rates in axillobifemoral
and axillofemoral grafts (unilateral) of 621 and

273 ml/min respectively, measured by LoG-
erfo and associates.6

It is not unusual to find atheromatous dis-
ease in the innominate, subclavian, or prox-
imal axillary arteries in those patients who
have severe abdominal aortic disease, and
sometimes this involvement is unrecognized.
The axillofemoral graft can be doomed to
failure should compromise of these arteries
exist. Another advantage of the thoracic aortic
femoral graft over the axillofemoral graft is
that the length of the conduit is much shorter
and conventional bifurcated grafts can be used.
The exposure to bending and external com-
pression is less.

In our practice we continue to use the more
conventional bypass procedures such as in-
frarenal aortic grafts, thrombectomy via the
femoral approach for clotted grafts, and ax-
illofemoral and femoral to femoral grafts.
However, we will be much more inclined to
utilize the thoracic aorta to femoral artery graft
wrhen it is anticipated that it will be a less
hazardous and more effective procedure.

SUMMARY

Two patients have been presented for whom
the selection of a thoracic aorta to bifemoral
artery bypass graft was necessary because the
abdominal aorta was too compromised to be
used as an outflow conduit. Both patients
gained a most satisfactory7 result.

The indications and contraindications for
this procedure and its technique are cited. It is
stressed that this operation should be selected
for those patients for whom the more conven-
tional bypass routes are not feasible or are
hazardous. This merely gives the surgeon an-
other option where circumstances are
complicated.

The surgical approach is usually straightfor-
ward and is associated with low morbidity and
mortality. Patency rates and flow rates com-
pare equally with the abdominal aortic to
femoral bypass grafts. □

June 1989

285

REFERENCES

1. Blaisdell FW, DeMattei GA, Gauder PJ: Extra-
peritoneal thoracic aorta to femoral bypass graft as
replacement for an infected aortic bifurcation pros-
thesis. AM J Surg 102:583-585, 1961.

2. McCarthy WJ, Rubin JR, Flinn WR, Williams LR,
Bergan JJ, Yao ST: Descending thoracic aorta-to-
femoral artery bypass. Arch Surg 121:681-688.

3. Schultz RD, Sterpetti AV, Feldhaus RJ: Thoracic aorta
as source of inflow in reoperation for occluded aor-
toiliac reconstruction. Surg 100:635-644, 1986.

4. Lakner G, Lukacs L: High aortoiliac occlusion: Treat-
ment with thoracic aorta to femoral arterial bypass. J.
Cardiovasc Surg 24:532-534, 1983.

5. Froysaker T, Skagseth E, Dundas P, Hall KV: Bypass
procedures in the treatment of obstructions of the ab-
dominal aorta. J Cardiovasc Surg 14:317-321, 1973.

6. LoGerfo FW, Johnson WC, Corson JD, Vollman RW,
Weisel RD, Davis RC, O’Hara ET, Nabseth DC, Man-
nick JA: A comparison of late patency rates of ax-
illobilateral femoral and axillounilateral femoral grafts.
Surg 81:33-40, 1977.

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286

The Journal of the South Carolina Medical Association

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MYASTHENIA GRAVIS PRESENTING AS
RESPIRATORY FAILURE: CONFUSION WITH
A PSYCHIATRIC ILLNESS*

C. BRYAN JORDAN, II, M.D.

HAROLD G. MORSE, M.D.**

LARRY S. ATKINSON, M.D.

Respiratory failure is a well known com-
plication of myasthenia gravis. Onset may be
sudden or insidious. In two recent reviews1’ 2
myasthenic patients requiring mechanical
ventilation for respiratory failure ranged from
7.6-20% of patients with known disease. Respi-
ratory insufficiency is often difficult to detect
early in the disease. In none of the reviewed
cases was respiratory failure the presenting
symptom.

We shall discuss a fatal case of respiratory
failure in an undiagnosed myasthenic in whom
confusion with a psychiatric disorder ham-
pered appropriate management.

CASE REPORT

A previously healthy 16-year-old black
female presented to the emergency room of
Anderson Memorial Hospital with a chief
complaint of abdominal pain. The emergency
physician found the patient lying naked on the
floor of the examining room. She gave no his-
tory of weakness and exhibited no weakness
when assisted to the examining table. Physical
examination was recorded as normal except
for a mild tachypnea (24 per min.), flattened
affect, and withdrawn, inappropriate behavior.
There was no evident lid lag, difficulty with
speech or secretions, or muscle weakness. Past
medical history obtained from family at this
time revealed only a long history of school
adjustment problems and street drug abuse.
She was noted to be a regular patient at the
local mental health clinic. Psychiatric con-
sultation was obtained and admission was
made to the psychiatric ward for observation.

* From the Family Practice Residency Program, Ander-
son Memorial Hospital.

** Address correspondence to Dr. Morse at 819 N. Fant
Street, Anderson, S.C. 29621.

Twelve hours after admission, the patient was
noted to have shallow rapid respirations and
appeared dyspneic to members of the nursing
staff. Vital signs were recorded, pulse 76 beats/
min., blood pressure 140/70mm Hg, respira-
tory rate 28/min. Medical consultation was
requested. Physical exam was again normal
excepting a respiratory rate of 28/min. and
inappropriate, withdrawn behavior. There
were no findings of muscle weakness. Portable
chest roentgenogram was normal. Serum elec-
trolytes, glucose and urea nitrogen were nor-
mal. Complete blood count revealed only a
mild lymphopenia.

Fifteen hours after admission, arterial blood
gases showed a mild respiratory acidosis (pH
7.32 PC02 56, P02 77). Urine toxicology
screen was requested, and the patient was
moved to a room where more frequent obser-
vation and hourly vital signs could be ob-
tained. Eighteen hours after admission, the
patient was noted to be ambulatory on the unit
without apparent difficulty, watching televi-
sion, and conversing on the phone. Shortly
after returning to her room, she was found
unresponsive on the floor of her room without
pulse or respiration. Attempted cardiopulmo-
nary resuscitation was unsuccessful.

Postmortem examination demonstrated dif-
fuse thymic hyperplasia. Lymphoid nodules
with active germinal centers were scattered
throughout the thymus and found to impinge
upon the cortex in many areas (Fig. 1). There
was no evidence of thymoma. Postmortem
toxicologic analysis of urine and vitreous
humor by thin layer chromatography was
negative. Acetylcholine receptor binding anti-
bodies obtained at postmortem and reported at
Mayo Medical Laboratories revealed a value
of 39.5 nanomoles per liter (normal less than

292

The Journal of the South Carolina Medical Association

MYASTHENIA GRAVIS

FIGURE 1.

0.03 nanomoles/ 1). Postmortem diagnosis was
myasthenia gravis leading to respiratory arrest.

DISCUSSION

Myasthenia gravis is a systemic neu-
romuscular disorder of immunologic origin. It
was first described in 1 672 and is characterized
by weakness and undue fatigability. The most
frequently affected muscles include the
oculomotor, facial, laryngeal, pharyngeal,
proximal limb and respiratory muscles.
Females are affected twice as often as males.
Onset of the disease is usually insidious but
may be acute. Physical findings on examina-
tion are often subtle. Dr. Samuel Wilkes at the
Guy’s Hospital in London describes this quite
well in 1877 in what is widely regarded as one
of the earliest case reports of the disease. “A
stout girl, looking well, came to the hospital on
account of general weakness; she could
scarcely walk or move about. She spoke slowly
and had slight strabismus. The house physi-
cian was inclined to regard the case as one of
hysteria. Every movement of her limbs and
speech was performed so slowly and deliber-
ately that the case seemed rather one of leth-
argy from want of will than actual paralysis. It
was shortly afterwards seen that her respira-
tions were becoming affected, the difficulty of
which rapidly increased and in a few hours, she
died.”3

Respiratory failure in myasthenics may be
precipitated by surgery4 or infection.1 It is also

seen in cholinergic crisis due to retention of
excess secretion from an ineffective cough, or
in myasthenic crisis due to weakened respira-
tory muscles.1’ 5 Medications including ami-
noglycides, D-penicillamin, Quinidine, pro-
cainamide, and phenytoin may precipitate a
myasthenic crisis or induce a myasthenic syn-
drome.6 Physical findings may be subtle and
the first noted change may be simply a fall in
vital capacity.2 Decreased ventilatory effort
results in mild hypoxemia, reflex tachypnea
and respiratory alkalosis. Tachypnea then
hastens muscle fatigue which can lead rapidly
to respiratory arrest. Prior to introduction of
anticholinesterase drugs in 1934, this most
feared complication of myasthenia resulted in
an 8% mortality rate during the first year of
disease.2 In the 1960’s, mortality from respira-
tory failure in myasthenia approached up to
70%. More recent studies have displayed mor-
tality from this complication at 26% and 5% in
1979 and 1983 respectively.5’ 1 This is almost
certainly due to an improvement in ventilatory
care. Of note is that all reported survivors
carried a known diagnosis of myasthenia
gravis which preceded respiratory failure. In
none was respiratory failure the presenting
symptom of myasthenia gravis as occurred in
the present case.

Correction of the condition precipitating
respiratory failure is critical to successful man-
agement of the respiratory complications. In
monitoring a patient’s respiratory status, one
must remember that considerable weakness of
respiratory muscles is present before changes
in blood gases are evident. In a previously
diagnosed patient, more immediate informa-
tion may be obtained by measuring maximal
static respiratory forces, maximum expiratory
pressure and maximum inspiratory pressure,
and vital capacity. These may be measured at
the bedside by trained personnel and may pro-
vide the earliest indicators of impending respi-
ratory failure.1 Appropriate therapy may then
be instituted before serious complications
occur.

This atypical case reminds us that my-
asthenia gravis should be considered in the
differential diagnosis of all patients with unex-
plained respiratory failure. □

June 1989

293

MYASTHENIA GRAVIS

REFERENCES

1. Gracey D, Divertie M, Howard F: Mechanical ventila-
tion for respiratory failure in myasthenia gravis. Mayo
Clin Proc 58:597-602, 1983.

2. Ferguson IT, Murphy RP, Lascelles RG: Ventilatory
failure in myasthenia gravis. Journal of Neurology, Neu-
rosurgery and Psychiatry 45:217-222, 1982.

3. Wilks S: Guy’s Hospital Reports 37(3):22, 54, 1877.

4. Ashworth B, Hunter AR: Respiratory failure in my-
asthenia gravis. Proc R Soc Med 64:489-490, May 1971.

5. Nowakowski J: Myasthenia gravis. Ann Emerg Med
11:272-275, May 5, 1982.

6. Argov A, Mastaglia F: Disorders of neuromuscular
transmission caused by drugs. N Engl J Med
301:409-413, August 23, 1979.

PHYSICIAN RECOGNITION AWARDS

The following SCMA physicians are recent recipients of the AMA’s Physician Recognition

Award. This award is official documentation of Continuing Medical Education hours earned.

John G. Appleby, M.D.

Gerard C. Jebaily, M.D.

William J. Bannen, M.D.

Arthur S. Jenkins, M.D.

J. M. Bennett, M.D.

James L. Jewell, M.D.

Robert H. Burley, M.D.

William K. Jones, M.D.

Rufus H. Cain, M.D.

Eugene M. Lepine, M.D.

John E. Carlton, M.D.

Needham L. Long, M.D.

David L. Castellone, M.D.

Woodrow W. Long, M.D.

Themistocles J. Chakeris, M.D.

Ravinder Malik, M.D.

Jose D. Chavez, M.D.

J. Frank Martin, M.D.

Mark A. Clark, M.D.

Robert E. Mitchell, M.D.

Rex H. Dillingham, M.D.

Joseph K. Newsom, M.D.

James K. Dixon, M.D.

Benjamin E. Nicholson, M.D.

Leonard W. Douglas, M.D.

Darius G. Ornston, M.D.

Robert S. Eagerton, M.D.

Mark F. Paris, M.D.

Bruce C. Elliott, M.D.

Harrison L. Peeples, M.D.

Clyde H. Flanagan, M.D.

Count Pulaski, M.D.

Peter Frank, M.D.

George L. Rainsford, M.D.

Everett P. Fuller, M.D.

David L. Richardson, M.D.

Stephen R. Gardner, M.D.

Ted J. Roper, M.D.

James S. Garner, M.D.

Stephen F. Serbin, M.D.

Henry W Gibson, M.D.

John R. Smith, M.D.

Winston Y. Godwin, M.D.

Palmira M. S. Snape, M.D.

Sidney T. Griffin, M.D.

Halsted M. Stone, M.D.

Gerald E. Harmon, M.D.

Clifton W. Straughn, M.D.

Robert D. Harper, M.D.

Frederick C. Swensen, M.D.

Harvey F. Hatcher, M.D.

John P. Taylor, M.D.

Henry B. Hearn, M.D.

William H. Thompson, M.D.

Hoke F. Henderson, M.D.

Robert W. Todd, M.D.

Edwin C. Hentz, M.D.

Warren G. Tucker, M.D.

David W. Hiott, M.D.

Wiley H. Turner, M.D.

David A. Howell, M.D.

Samuel E. Wood, M.D.

Roy A. Howell, M.D.

294

The Journal of the South Carolina Medical Association

DISPENSE AS WRITTEN

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The patients are yours.

The prescriptions are yours.

Make the prescribing decision yours, too.

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“Dispense as written” line.

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Editorial

TRUE (PALMETTO) BLUE

Whatever controversy may have been pre-
sent at the recent, 141st annual meeting of our
association passed largely unnoticed. The pre-
vailing tones were good will and efficient orga-
nization. If any group of persons complained,
it must have been the news reporters. They
seemed hard-put to find anything controver-
sial to write about.

Nevertheless, one theme was heard over and
over, both publicly and privately: “We’re going
to hear more and more about socialized
medicine.”

The theme is hardly new. I can remember
my own father, a physician, gently suggesting
back in the ’50s that I might consider another
field: “Medicine’s going to be socialized; the
politicians want to play Santa Claus.” Like
most physicians of his day, he charged reason-
able fees for those who could pay and treated
numerous others with little or no hope for
reimbursement. Medicare and Medicaid re-
duced the numbers of such patients but made
prophets of those who warned of the Trojan
horse effect. What characterized this year’s an-
nual meeting was a new sense of fatalism that
socialized medicine will happen — in the near
future.

On Sunday morning, we were told that
movement in this direction would be media-
driven. We were reminded that a Harris poll of
3,000 Americans showed that 89% favored a
change in health care financing and that 62%
specifically favored the Canadian system. In
his inaugural address the previous evening, Dr.
Daniel Brake shared with us the conclusion of
Canadian medical leaders that nobody seems
especially happy with that system. Politicians
have stopped talking about unlimited compre-
hensive care; patients endure long waits for

elective procedures; physicians experience
anxiety over their loss of control. Our new
president outlined his plan for a committee to
study the alternatives and urged that all physi-
cians must become involved in organized
medicine.

The agenda before the editorial board of The
Journal at its annual meeting was less formida-
ble. We did, however, discuss a number of
issues — one of which was our cover. Joy Dren-
nen provided us with an alternative format for
the journal and suggested two basic schemes:
white (with blue lettering) or blue (with white
lettering). After some discussion, blue pre-
vailed. Someone suggested that it ought to be
Palmetto blue. Everyone liked the idea, and we
charged our printer to find a true Palmetto
blue.

It seems appropriate that the new cover and
the new call for involvement should coincide.
We now prepare for events destined to shape
the face of medical practice for the year 2000.
The Journal and the SCMA have grown and
changed together ever since the year 1900,
when Dr. Walter P. Porcher of Charleston
urged the formation of a journal at the SMCA’s
golden anniversary meeting. Our organization
had scarcely 150 members and essentially no
money at the time; a journal was considered to
be impractical. Five years later, however, the
House of Delegates determined “that a journal
would be of the greatest value in strengthening
and maintaining” our organization and that
every member “should regard it as a duty to
work for its success.”1 The first cover featured
the table of contents and the names of the
association’s officers. In time, The Journal
came to symbolize medicine in South Carolina
and to be a source of pride. It is our hope that

296

The Journal of the South Carolina Medical Association

having each cover be the same, deep blue will
enhance recognition of The Journal and hence
visibility of our organization.

A high point of this year’s annual meeting
was Dr. Charles Sasser’s Sunday morning ad-
dress to the House of Delegates. He asked us to
imagine that all of our socioeconomic prob-
lems have been filed away. What, then, re-
mains? Dr. Sasser’s concept of “the wounded
healer” touched everyone. Implicit in this con-
cept is the notion that we are professionals, not

tradesmen, and that our concerns far transcend
our own economic betterment. We must re-
emphasize this message. The Journal, for its
part, is of the South Carolina Medical Associa-
tion but for South Carolinians.

True (Palmetto) Blue.

— CSB

REFERENCE

1. Waring JI: History of medical journalism in South
Carolina. J SC Med Assoc 51: 185-191, 1955.

ON THE COVER:

EARLY MEDICAL JOURNALISM IN SOUTH CAROLINA

In appreciation of the dramatic change in the
format of The Journal, we thought a backward
look at earlier medical journalism in South
Carolina might be in order. Our cover this
month shows the title page of the first such
effort, The Charleston Medical Register for
1802, established by the renowned historian
and physician of Charleston, Dr. David Ram-
say. This pamphlet was proposed to continue
as a periodical which would give accounts of
local medical affairs. Unfortunately volume 1,
number 1 was the first and last of this series.

The next attempt, the quarterly Carolina
Journal of Medicine, Science and Agriculture,
established in 1 825 and edited by Drs. Thomas
Y. Simons and William Michel, lasted one
year.

The Southern Journal of Medicine and Phar-
macy published two volumes before changing

its name in 1848 to The Charleston Medical
Journal and Review. This publication flour-
ished until 1877 with a hiatus of 13 years dur-
ing and after the war. The Charleston Journal
was “received in every state of the South and
West . . . [and] there was no journal in this
section of the country . . . more frequently
searched and quoted from.”

After the demise of the Charleston Journal,
there was no medical periodical for the state
until the founding of the Journal of the South
Carolina Medical Association in 1905, which
will be another story.

Betty Newsom

The Waring Historical Library

Excerpted from an article by Joseph I. Waring,
M.D.

June 1989

297

MEDICINE,

PHYSICIANS
AND
FLIGHT.

MAJOR CHUCK HELVEY
919-850-9549
Station-To-Station Collect

This space contributed as a public service.

298

The Journal of the South Carolina Medical Association

Kwcmavo Page

HEALTH EDUCATION TAKES TO THE ROAD IN SOUTH CAROLINA

When the state legislature passed the South Carolina Comprehensive Health Education Act in
1988 mandating health education for all students from kindergarten through twelfth grade, the
SCMA Auxiliary proposed a unique concept to assist in fulfilling this objective: MOBILE HEALTH
EDUCATION.

The Auxiliary, long concerned about South Carolina’s numerous health problems, actively
supported passage of this health legislation. Feeling an urgency to assist in fulfilling its objectives, a
group of auxilians originated the idea of purchasing and outfitting a Health Education Van that
would carry portable health exhibits, teaching aids and special teachers to promote wellness and
disease prevention throughout the state.

The first order of business was to elicit the collaboration of Dr. Charlie G. Williams, State
Superintendent of Education, to assist in developing the plan from “concept to concrete.” Repre-
sentatives of the Van Committee visited the Robert Crown Center in Hinsdale, Illinois, to learn
their methods for teaching health using three-dimensional exhibits. The knowledge gained there
was integrated with the previously determined health needs in South Carolina to define the
following teaching areas: Substance Abuse Education, Reproductive Health Education, Nutrition
Education, Pregnancy Prevention, Sexually Transmitted Diseases and AIDS Education.

To purchase the van and its exhibits, the SCMA Auxiliary joined forces with the SCMA and its
charitable foundation, the S. C. Institute for Medical Education and Research (SCIMER) to mount
a fund-raising campaign. The medical community, including individuals, medical societies, and
100% of the county auxiliaries, contributed generously, raising the necessary funds in less than a
year.

A grant from the Centers for Disease Control in Atlanta, Georgia, made it possible to include
materials for AIDS education. The S. C. Depatment of Education received state funding to hire two
specially trained health educators to operate the van and provide exhibit-oriented training and
instruction to teachers and students in the state. Dr. Bambi Sumpter and Dr. Katy Wynn were
chosen to be the Health Education Van Consultants because of their dynamic personalities as well
as for their exceptional educational qualifications and experience in the health education field.

The van’s portable three-dimensional exhibits were created by the Richard Rush Studio, Inc., of
Chicago, which has experience in designing health centers and displays worldwide. The exhibits can
be set up in a classroom-like mode with two eight-foot snap out frames covered with velcro used as a
background. Spotlights are fastened to the backdrop to illuminate the exhibits. Each exhibit has its
own earning case and can be tightly secured by straps on the shelves of the van during travel.

The Health Education Van serves as a supplement to textbooks. Classes of approximately 35
children per hour provide optimum teacher/student contact. The exhibits and educational mate-
rials are programmable for all ages. The van is available for use by community groups and county
medical societies and auxiliaries as often as the Department of Education schedule permits.

A news conference was held on February 21, 1 989 to introduce the van to the media, and the van
was on display on the State House Grounds. Governor Carroll Campbell signed a proclamation
declaring the day to be TOTAL HEALTH DAY in recognition of the progress being made toward a
healthy citizenry. The van has since been travelling the roads of South Carolina, including a trip to
Charleston where it and the exhibits were on display during the SCMA and SCMA Auxiliary
Annual Meetings.

Excerpted from an article by Maggie Bowles and Nancy White which appeared in Facets.

June 1989

301

Re -introduce The Oldest
Advance In Medicines.

It’s called talking. Right or wrong, many older people today
feel that doctors just don’t spend as much time talking
with their patients as they used to. Things seem more
rushed and hurried.

But talking, especially about medicines, is more important
than ever before. Your older patients may be taking several
different medicines and seeing more than one doctor. And
many older people are treating themselves with over-the-
counter drugs.

Unfortunately, an older person’s response to medicines is
less predictable than a younger person’s. They can experience
altered drug actions and adverse drug reactions.

So, if they don’t tell you first, ask them what they’re taking
and if the medicines are causing any problems. Take a
complete medications history including both prescription
and non-prescription medicines.

Make it a point to tell them what they need to know — the
medicine’s name, how and when to take it, precautions, and
possible side effects. Give them written or printed information
they can take home, and encourage them to write down
what you tell them.

Good, clear communication about medicines can increase
compliance, prevent problems, and lead to better health.

So re-introduce the oldest advance in medicines. Make
talking a crucial part of your practice. It isn’t a thing of the
past. It’s the way to a healthier future.

Before they take it,
talk about it.

^ ^ National Council on

mr Patient Information and Education.

** " 666 Eleventh St. N.W. Suite 810

Washington, D.C. 20001

VOLUME 85

JULY 1989

NUMBER 7

LYME AND OTHER TICK-BORNE DISEASES
ACQUIRED IN SOUTH CAROLINA IN 1988:

A SURVEY OF 1,331 PHYSICIANS*

STANLEY H. SCHUMAN, M.D., Dr. P.H.

SAMUEL T. CALDWELL, M.A.

During 1988, physicians reported to the
South Carolina Department of Health and En-
vironmental Control 23 cases of Rocky Moun-
tain Spotted Fever (RMSF) and ten cases of
Lyme disease. Unlike RMSF, many states do
not require the reporting of Lyme disease. In
1989, Lyme disease and ehrlichiosis were
made reportable diseases in South Carolina.1

Lyme disease was first diagnosed in Con-
necticut in 1975. This spirochetal infection
(Borrelia burgdorferi) has spread through the
east, the upper midwest and western portions
of the U.S.2 Since 1 980; sporadic cases of Lyme
disease have been reported in the south; Geor-
gia in 1980, 3 Arkansas in 1982, 4 and North
Carolina in 1983. 5 In 1988, serologically con-
firmed cases were documented6 in the follow-
ing southeastern states: Alabama — 1, Geor-
gia— 59, North Carolina — 12, Tennessee — 13
and Virginia — 25. The first case in South Caro-
lina was reported in 1 98 57 and involved a nine-
year-old boy infected during the summer of
1984.

The authors’ interest in Lyme disease in-
creased after a relative of a co-worker and a
Sumter County client of the Cooperative Ex-
tension Service developed clinical symptoms

* From the Agromedicine Program, Department of Family
Medicine, Medical University of South Carolina, 171
Ashley Avenue, Charleston, SC 29425 (address corre-
spondence to Dr. Schuman).

following tick bites in the late summer and fall
of 1 988. A survey was needed to determine the
extent of Lyme and other tick-borne disease in
South Carolina.

METHODS

A field tested questionnaire with postage-
paid return envelope was mailed to each of
2,346 primary care physicians in South Caro-
lina. The survey population was identified by
practices listed in the 1988-1989 Directory of
the State Board of Medical Examiners as fam-
ily practice, internal medicine, pediatrics, gen-
eral practice, emergency medicine or occupa-
tional medicine. The physicians were asked to
report total cases of tick-borne infection, ac-
quired in South Carolina, diagnosed or treated
in 1988 and to classify each case by age group,
hospitalization and category of tick-borne dis-
ease. Case definitions or exclusions were not
provided. The category of “other tick-borne
disease” was intended to retrieve any case of
tick-related fever including the newly de-
scribed ehrlichiosis, as well as cases which the
respondent was reluctant to classify in the ab-
sence of laboratory confirmation. Because of
special interest in Lyme disease, physicians
were asked to specify the number of Lyme
disease cases that were serologically confirmed
and to describe their most interesting case on
the back of the form.

July 1989

311

TICK-BORNE DISEASES

RESULTS

A total of 1,331 questionnaires (57%) were
returned. Sixteen percent (n = 213) of the re-
sponding physicians reported diagnosing or
treating one or more cases of tick-borne dis-
ease. Family practice physicians accounted for
54% of the cases, internists for 18%, pediatri-
cians and emergency room physicians for 1 1%
each, general practice 5% and occupational
medicine < 1 %. Family practice accounted for
a slightly greater percentage of Lyme cases
(54% cases versus 49% proportion of re-
spondents). Respondents who reported cases
diagnosed or treated by other physicians under
their supervision as well as identical reports
from members of the same group practice were
excluded in order to avoid double reporting.

Respondents reported 467 cases of tick-
borne disease in South Carolina in 1988; 344
cases of RMSF, 90 cases of Lyme disease and
33 cases of other tick-borne disease (Table 1).
Serological confirmation was reported for 34
(38%) of the Lyme disease cases. Children 14
years of age and younger accounted for 40% of
the RMSF cases, 23% of the Lyme disease and
18% of the other tick-borne disease category.
Thirty-five percent of RMSF cases required
hospitalization as compared to 20% of the
Lyme disease cases and only nine percent of
the other tick-borne disease (Table 2).

Table 3 lists the cases of RMSF, Lyme dis-
ease and other tick-borne disease by county of
practice of the reporting physicians. The upper

Piedmont region of the state accounted for the
majority of RMSF cases. Seventy-one percent
of the total occurred in seven counties: Ander-
son, Cherokee, Chester, Greenville, Pickens,
Spartanburg and York. Lyme disease was re-
ported in 27 counties throughout the state.
Richland County had the most cases of Lyme
disease (n=16) followed by Charleston
County with 10 cases. Serologically confirmed
cases of Lyme disease (n = 34) were also dis-
tributed throughout the state with Richland
and Greenville Counties accounting for 40% of
the total. Reports of other tick-borne infections
were also scattered around the state. Almost
40% (n = 1 3) of the cases in the other tick-borne
disease category were reported in Hampton
County. One Hampton County physician re-
ported a series of ten cases in timber workers
who developed flu-like symptoms following a
history of tick bite. Rashes were not detected in
these patients, but all responded to antibiotics.

DISCUSSION

Is 1988 a transition year for the diagnosis
and treatment of tick-borne disease in South
Carolina? With more cases of Lyme disease
being recognized across the country and more
emphasis on early diagnosis and treatment,
responding physicians made nine times as
many diagnoses of Lyme disease in 1988 than
were reported to the health department. It
must be remembered that Lyme was not a
reportable disease in 1988. The discrepancy

TABLE 1

1988 Physician Survey of Tick-Borne Disease in South Carolina

Case Reports a

Tick.

Total

Hospitalized

Not Hospitalized

Borne

Cases

<14

>15

<14

>15

Disease

Reported

Age

RMSF

344

104

110

LYME

90b

OTHER

TOTAL

467

124

177

a Hospital status was not reported for 10 cases of RMSF, 10 cases of Lyme disease and five cases of other tick-borne disease.
b 34 cases were serologically confirmed.

312

The Journal of the South Carolina Medical Association

TICK-BORNE DISEASES

TABLE 2

Severity of Tick-Borne Disease
As Indicated By Hospitalization Rates
(Percent =N Hospitalized/N Cases x 100)

Category

Age < 14

Age > 15

Total

RMSF

344*

25%

44%

35%

LYME

29%

20%

OTHER

17%

TOTAL

467

25%

36%

30%

* Two deaths reported

between the number of survey cases and
number of reported cases is not unexpected. In
New Jersey, with eight years of experience with
Lyme disease, 1,400 cases were reported to the
health department which accounted for only
25% of the estimated treated cases.8 In Geor-
gia, where the health department laboratory
offered free laboratory analysis in 1988, the
number of serologically confirmed cases in-
creased from four in 1987 to 59 in 1988. 9
Wisconsin will show at least a 50% increase in
reported cases of Lyme disease during 1988
(from 500 to 1,000) due to the voluntary re-
porting of one large medical center which has
been quietly diagnosing and treating cases for
three years without making reports to their
health department.10 Thus the incidence, prev-
alence and trends of Lyme disease are still
being pieced together from clinical and public
health sources of data.

Entomologists nationwide are still trying to
explain the increased number of human cases
and co-host cases (cats, dogs and cattle) in
urban and suburban areas. The ecology of
parasitism in Lyme disease requires teamwork
among clinicians, entomologists and veterin-
arians.

The county distribution in Table 3 should be
interpreted with caution since the residence of
each patient was not charted in this survey.

In the meantime, a practitioner in South
Carolina is faced with the following facts:

(a) S.C. is endemic for tick-borne RMSF,
whose vector is the dog tick. Similarity of
hosts, habitat and climate for Lyme disease
exists. Twenty-seven of 46 counties report
Lyme disease so far.

TABLE 3

Reported Cases of Tick-Borne Disease
In South Carolina By County of
Physician Respondent, 1988

County

Total

RMSF

Lyme (n)a

Other

Abbeville

Aiken

(1)

Anderson

Bamberg

Barnwell

Beaufort

(2)

Berkeley

(1)

Charleston

(2)

Cherokee

Chester

Colleton

Darlington

Dillon

Dorchester

(2)

Edgefield

Fairfield

Florence

(2)

Georgetown

Greenville

(4)

Greenwood

(1)

Hampton

13b

Horry

(2)

Jasper

Lancaster

(1)

Laurens

Lexington

Marion

Marlboro

McCormick

Newberry

Oconee

Orangeburg

(1)

Pickens

(1)

Richland

(10)

Saluda

Spartanburg

Sumter

Union

York

(3)

a Serologically confirmed cases, n=34

b Ten of 13 cases were reported by a single physician; all
patients were timber workers who developed flu-like
symptoms following tick bites.

July 1989

313

TICK-BORNE DISEASES

(b) A tick survey for the principal Ixodes vec-
tors of Lyme disease in S.C. has yet to be
conducted. A team of Clemson University
and University of South Carolina ento-
mologists plans to study ticks in relation to
recent human cases in 1989.

(c) Clinical spectrum of Lyme disease involves
all the systems and the three classic stages
of another treponematosis (syphilis), with
similar serious consequences for delayed
or inadequate antibiotic treatment, relapse
or reinfection.11

(d) Current methods of serologic confirmation
of diagnosis are inconsistent and vary with
the stage of infection, treatment, immu-
nologic response to borrelia and quality of
laboratory. Isolation of borrelia from le-
sions, confirmed by specific staining and
dark-field microscopy, is the only unques-
tioned standard for diagnosis.

(e) For the patient, prudent behavior is to prac-
tice tick-hygiene. This worked for decades
to prevent Colorado tick-fever and rickett-
sioses. One should note time and report
unusual symptoms and rashes after tick
exposure to one’s physician. The latest in-
formation on tick control can be obtained
from the county Cooperative Extension
Service office.

(f) For the physician, prudent behavior is to be
alert to the likelihood of Lyme disease vec-
tors in his community. Case-reports from
Wisconsin, New Jersey and New England
are increasingly regarded as “backyard” in-
fections. One needs to recognize the early
stages of Lyme with and without the rash.
The advantages of early diagnosis, appro-
priate antibiotics, follow-up, and evalua-
tion are self-evident.

(g) Case-reporting to the South Carolina De-

partment of Health and Environmental
Control should be encouraged. This will
help define the frequency, severity and dis-
tribution of cases. It may help funding for
concerned agencies to improve their ser-
vices and to limit morbidity. This survey
can serve as a first step.

SUMMARY

2,346 primary care physicians were sur-
veyed by mail to estimate the number of cases
of tick-borne fever diagnosed by them during
1988. The results of the 57% response reveal
344 cases of Rocky Mountain Spotted Fever,
90 cases of Lyme disease and 33 other tick-
borne disease cases acquired in South Caro-
lina. The implications for a greater level of
clinical awareness and a search for endemic
vectors and animal hosts are emphasized. □

REFERENCES

1. Personal communication. Dr. J. Jones, Disease Con-
trol, South Carolina Department of Health and En-
vironmental Control. April 1989.

2. Stechenberg BW: Lyme disease: the latest great im-
itator. Pediatr Infect Dis J 7: 402-409, 1988.

3. Centers for Disease Control: Rocky mountain spotted
fever— United States 1980. MMWR 30: 318-320,
1981.

4. Centers for Disease Control: Lyme disease. MMWR
31: 367-368, 1982.

5. Pegram PS, Sessler, CN, London WL: Lyme disease in
North Carolina. South Med J 76: 740-742, 1983.

6. Personal communication. Dr. R. Craven, Centers for
Disease Control, April 1989.

7. Taylor RD, Harris MP: Lyme disease: a case report
from South Carolina. JSC Med Assoc 81: 419-420,
1985.

8. Personal communication. Dr. T. Schulze, New Jersey
State Department of Health. April 1989.

9. Personal communication. Dr. R.K. Sikes, Georgia De-
partment of Human Resources. March 1989.

10. Personal communication. Dr. P. Layde, Marshfield
Clinic, Marshfield, Wisconsin. April 1989.

1 1. Benenson AS: The continuing saga of Lyme disease.
AJPH 79: 9-10, 1989.

314

The Journal of the South Carolina Medical Association

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316

The Journal of the South Carolina Medical Association

ACUTE PANCREATITIS IN A
FIVE-YEAR-OLD MALE*

TIMOTHY J. MADER, M.D.
JETER P. TAYLOR, M.D.
TERRANCE P. McHUGH, M.D.

Acute pancreatitis is frequently not consid-
ered as a cause of abdominal pain in children.
However, the recent medical literature has
challenged this view; current estimates suggest
the overall incidence of acute pancreatitis in
children is one in 50,000, or ten times greater
than previously reported.1 We present a case
report to make physicians more aware of this
entity.

CASE REPORT

A five-year-old black male presented to the
ED after waking up with severe epigastric pain.
His mother stated he had been complaining of
some nausea and loss of appetite earlier in the
day; additionally, he had had no bowel move-
ment in the past three days. She denied any
history of fever, chills, recent viral illness,
sickle cell anemia, dysuria, insect bites, antece-
dent trauma or recent use of medication. The
child, himself, only complained of abdominal
pain. He had several episodes of clear emesis
while in the ED.

On physical examination, the patient ap-
peared to be in mild distress. He weighed 26 kg.
Vital signs included: oral temperature, 98°F;
pulse, 80 beats/minute; respiratory rate, 20
breaths/minute; and blood pressure, 116/74
mmHg. Examination of the head, neck, lungs,
and cardiovascular system were within normal
limits. The abdomen was soft, but exhibited
tenderness to light palpation of the right upper
quadrant and epigastrium. Bowel sounds were
auscultated in all four quadrants; no rebound
tenderness, masses, hepatosplenomegaly or
psoas sign was detected. Rectal exam demon-
strated the presence of hard, guaiac-negative
stool. His skin had good turgor and no rash was
seen.

* From the Department of Emergency Medicine, Richland

Memorial Hospital, Five Medical Park Road. Columbia.

S.C. 29203 (address correspondence to Dr. Mader).

An intravenous line of D50.2NS was started
and base line laboratory functions obtained.
The white blood cell count was 11,000 cells/
mm3; hemoglobin, 12.0 g/dL; and hematocrit,
34.7%. Urinalysis revealed a specific gravity of
1.026: pH. 5.0; glucose, 1000 mg/dL; ketones,
0; red blood cells, 0 cells/hpf; and white blood
cells, 20-25 cells/hpf. A sickledex test was nega-
tive. Abdominal roentgenograms revealed
abundant stool in the large colon, but no ab-
normal air/fluid levels or evidence of perfora-
tion were noted.

While being observed in the ED and despite
the passage of a large, firm stool, the patient’s
clinical condition worsened. Because of his
increasing pain, pediatric surgical consultation
was requested and additional laboratory stud-
ies ordered. Results included sodium, 150
mEq/L: potassium, 3.3 mEq/L; chloride, 104
mEq/L; serum bicarbonate, 25 mEq/L; glu-
cose, 242 mg/dL: BUN, 10 mg/dL; creatinine,
0.4 mg/dL; and serum amylase, 650 u/L. Re-
peat abdominal roentgenograms now demon-
strated the presence of a mild paralytic ileus.

Subsequently, the patient was admitted to
the pediatric service with a diagnosis of acute
pancreatitis; he was maintained at bed rest and
received only intravenous fluids for the next
several days. Abdominal sonography demon-
strated a diffusely enlarged, hypoechogenic
pancreas with no evidence of biliary obstruc-
tion or pseudocyst formation. A hepatitis
panel was negative for acute hepatitis A or B.
and a urine drug screen was only mildly
positive for the presence of caffeine. Viral
serology was negative.

The patient’s serum amylase reached a max-
imum of 934 u/L within 24 hours of admission
and then returned to normal over a three-day
period. His urinary amylase peaked at 3271 u/
L and also fell rapidly. After three days of
hospitalization, the patient was tolerating oral

July 1989

317

CHILDHOOD PANCREATITIS

liquids; he was discharged after five days with a
diagnosis of idiopathic pancreatitis.

DISCUSSION

Acute pancreatitis is often divided into two
types: an interstitial, or edematous variety; and
a fulminant, hemorrhagic form.2 While inter-
stitial pancreatitis usually follows a benign
clinical course, hemorrhagic pancreatitis can
be life-threatening, especially in children
where it carries a mortality rate of up to 86%.2
Overall, both types of pancreatitis have a mor-
tality rate of 30% in children, compared to 12%
in adults.3 Because it is difficult to predict a
patient’s course at the time of admission, every
case must be treated as a medical emergency.4
Unfortunately, in up to one-third of cases the
diagnosis is not suspected before surgery or
autopsy; a high index of suspicion remains
essential for early diagnosis and treatment.3

The list of identifiable causes of acute pan-
creatitis in children is constantly expanding as
new precipitating factors are recognized (see
Table 1). Although some etiological sim-
ilarities exist between children and adults,
their relative frequencies are quite different.
Approximately 70-85% of adult cases have ei-
ther underlying cholelithiasis or a history of
significant alcohol abuse; neither of these prob-
lems is typically encountered in the pediatric
population.2- 4 When an etiology can be clearly
established in childhood cases, 80% are sec-
ondary to trauma, medications, or infections;
the remaining 20% are either idiopathic, or
secondary to systemic diseases (particularly
sickle cell anemia and diabetes mellitus), ana-
tomic or hereditary factors.1’ 2’ 5> 6 Alcohol
ingestion remains an important consideration
in the older adolescent.

In recent reviews, numerous researchers
have found trauma to be the single most com-
mon etiological agent.2’ 3’ 5 Traumatic pan-
creatitis can follow surgical or major trauma;
however, it can also follow subtle, even forgot-
ten abdominal injury, such as falling across
bicycle handle bars or incidental contact dur-
ing sporting activities.1’ 3 Pancreatitis may also
be the sole manifestation of child abuse, ac-
counting for 10% of the total cases in one se-
ries.3’ 5

Medications caused 23% of the total cases in
the series reported by Cox.1 Drug induced pan-

creatitis may be due to a child’s own prescrip-
tion medications, such as valproic acid, corti-
costeroids, or tetracycline; parenterally admin-
istered drugs, such as azothioprine or L-as-
paraginase; or possibly the accidental ingestion
of other agents, such as oral contraceptives,
furosemide, or thiazide diuretics.1 Presently,
steroids are the most frequently implicated
medication causing pancreatitis.1’ 2

Infections presently account for 15% of
childhood cases, but this percentage is likely to
increase as the recognition and characteriza-
tion of infectious etiologies improve.1 Mumps
is currently the most common offender within
this category.1’ 2 Other infectious agents associ-
ated with acute pancreatitis include the Ep-
stein-Barr virus, cytomegalovirus, Hepatitis A
and B viruses, and others.1

In contrast to adults, abdominal pain in chil-
dren may be absent or nonepigastric in loca-
tion.1’ 5 The presenting complaints in children
can be vague, but commonly include lethargy,
fever, nausea, vomiting, or jaundice.1’ 2 The
physical examination is also likely to be non-
localizing, offering few clues to the correct di-
agnosis. The child typically lies very still on
one side. Abdominal distension, icterus, as-
cites or pleural effusion can occasionally be
detected clinically.1’ 2> 5 Sometimes, children
present subacutely with a palpable pseudo-
cyst.5

Currently, measurement of the total serum
amylase (SA) is the most widely performed
laboratory test. However, it has several limita-
tions: SA can be elevated in a number of other
pathological conditions;6 SA’s degree of eleva-
tion does not correlate with the severity of the
disease;5 SA levels rapidly return to normal
and may not be elevated if some delay in pre-
sentation has occurred;7 and SA levels may
never become elevated, even in histologically
proven cases.6' 8 Therefore, if doubt exists as to
the correct diagnosis, further testing may prove
useful. Because serum lipase values are more
specific than SA and remain elevated for a
longer period of time, they may aid confirma-
tion.1 Isoamylase measurements are also more
specific than SA; they may be of value, es-
pecially when coupled with a lipase determina-
tion.7 Trypsinogen assays are the most sensi-
tive and specific tests, but they are not widely
available.9 The ACCR (amylase creatinine

318

The Journal of the South Carolina Medical Association

CHILDHOOD PANCREATITIS

Table 1 — Etiology of Childhood Pancreatitis

Idiopathic

Hereditary

Traumatic

Blunt

Post-Operative
Child Abuse

Infectious

Mumps

Epstein-Barr

Hepatitis A and B

Cytomegalovirus

Rubella

Rubeola

Influenza A

Coxsackie B

Mycoplasma

Leptospirosis

Ascaris lumbricoides

Structural

Biliary Tract Disease
Cholelithiasis
Choledochal Cyst
Intraductal Duplication
Ductal Stricture
Annular Pancreas

Nonfusion of the Dorsal and Ventral Pancreas
Anomalous Insertion of the Common Bile Duct
Tumor

Toxic or Drug-Induced

Corticosteroids

Thiazides

Alcohol

Valproic Acid

Furosemide

Ethacrynic Acid

Tetracycline

Trimethoprim-Sulfamethoxazole

Sulfasalazine

Rifampin

Metronidazole

Oral Contraceptives

Azathioprine

Systemic Illness

Hyperlipidemia Types I, IV and V
Kawaski Disease
Cystic Fibrosis
Lupus Erythematous
Periarteritis nodosa
Hyperparathyroidism
Diabetes Mellitus
Renal Failure
Scholein-Henoch Purpura
Crohn's Disease
Glycogen Storage Disease I
Alpha 1-Antitrypsin Deficiency
Malnutrition
Perforated Peptic Ulcer

clearance ratio) has not been validated in the
pediatric population.6’ 10
Several imaging techniques are helpful in
confirming the diagnosis of acute pancreatitis.
While abdominal roentgenograms occasion-
ally demonstrate subtle, nonspecific signs,
such as a sentinel loop, they prove most useful
in excluding other intra-abdominal pa-
thology.4 Abdominal ultrasonography is an ex-
tremely valuable adjunct to clinical evalua-
tion; many consider sonography the imaging

technique of choice in childhood pancre-
atitis.1’ 5> 8- 10 When present, pancreatic en-
largement and hypoechogenicity are highly
suggestive of acute pancreatitis.1’ 10 If localized
areas of density are noted within the pancreas,
hemorrhagic pancreatitis should be consid-
ered. Pseudocysts can also be readily visu-
alized.5 The major limitation to ultrasound is
the presence of overlying, distended bowel
loops which preclude adequate examination in
approximately 14-25% of cases.5’ 8 Although

July 1989

319

CHILDHOOD PANCREATITIS

abdominal computed tomographic (CT) scan-
ning improves the resolution in pancreatic
imaging, it rarely provides additionally useful
clinical information.1 However, CT does have
definite utility in cases when ultrasonography
is technically inadequate or there is a need to
image other abdominal structures as well.5
This is a controversial area and some clinicians
consider CT to be the initial imaging technique
of choice.4

Other diagnostic modalities occasionally
employed include endoscopic retrograde chol-
angiopancreatography (ERCP), angiography,
isotopic scanning, peritoneal lavage and ex-
ploratory laparotomy.3’ 6 Fortunately, these
procedures are rarely, if ever, indicated in chil-
dren. ERCP is useful in demonstrating ob-
structing lesions or stones, ductal strictures,
duplication and other anatomic misalign-
ments; these are more often associated with
chronic, relapsing pancreatitis.1’ 6 Diagnostic
laparotomy should be avoided whenever pos-
sible.10

Complications of acute pancreatitis include
phlegmons, pseudocysts, abscesses, fistulas,
acute renal failure, and acute respiratory dis-
tress syndrome.1 Such complications are often
the result of a delay in correct diagnosis and
tend to be associated with increases in mor-
bidity and mortality.

SUMMARY

Acute pancreatitis should be considered in

all children presenting with acute abdominal
complaints. A complete history should be ob-
tained with emphasis on recent trauma, infec-
tions, current medications, and the presence of
any systemic diseases. Simple laboratory stud-
ies and non-invasive imaging techniques can
usually confirm the clinical suspicion. Most
cases of interstitial pancreatitis resolve un-
eventfully but hemorrhagic pancreatitis carries
a significant mortality risk. □

REFERENCES

1. Cox KL: Pancreatitis in Children. Pediatric Case Re-
ports in Gastrointestinal Diseases (Ross Laboratories)
1986; 6:1-7.

2. Jordan SC, Ament ME: Pancreatitis in children and
adolescents. Pediatrics 1977; 91:211-216.

3. Buntain WL, Wood JB, Woolley MW: Pancreatitis in
childhood'. J Ped Surg 1978; 13:143-148.

4. Moody FG: Pancreatitis as a medical emergency. Gas-
tro Clinics of N Am 1988; 17:433-493.

5. Ziegler DW, Long JA, Philippart AI, et al: Pancreatitis
in childhood: experience with 49 patients. Ann Surg
1988; 207:257-261.

6. Tam PKH, Saing H, Irving IM, et al: Acute pan-
creatitis in children. J Ped Surg 1985; 20:58-60.

7. Kolars JC: Comparison of serum amylase, pancreatic
isoamylase and lipase in patients with hyper-
amylasemia. Digest Dis Sci 1984; 29:289-292.

8. Coleman BG, Arger PH, Rosenberg HK, et al: Gray-
scale sonographic assessment of pancreatitis in chil-
dren. Radiology 1983; 146:145-150.

9. Steinberg WM, Goldstein SS, Davis ND, et al: Diag-
nostic assays in acute pancreatitis. Ann Int Med 1985;
102:576-580.

10. Cox KL, Ament ME, Sample WF, et al: The ultrasonic
and biochemical diagnosis of pancreatitis in children.
Pediatrics 1980; 96:407-411.

320

The Journal of the South Carolina Medical Association

NEWSLETTER

JULY 1989

MEDICAID UPDATE

Increase in the Number of Medicaid Recipients

The income eligibility limit for pregnant women and infants was
increased to 185% of the federal poverty guidelines effective
July 1, 1989. Under the new income guidelines, the Medicaid
program expects to sponsor 40 to 60 percent of the deliveries in
the state. The State Health and Human Services Finance
Commission hopes that providing sponsorship for health care for
more pregnant women and infants will be helpful in South
Carolina* s effort to reduce the infant mortality rate.

Adult Physicals

Physical exams for adults age 21 and older will be reimbursed by
Medicaid at a rate of $100 per examination effective July 1,
1989. These exams will be limited to one examination per
recipient every five years. Providers may submit claims using
procedure code 90750 and diagnosis code V70.9.

Back Transfer Policy for Neonates

Effective July 1, 1989, the following supplemental codes should
be used by pediatricians and family practitioners who accept NICU
graduates back to Level I and II hospitals:

Procedure Code Description

Reimbursement Rate

S9661

S9662

S9663

Initial hospital exam $100.00

for an infant transferred
from a Level III NICU

Subsequent care - extended $ 50.00/day

or intermediate hospital

care for a NICU graduate

transferred from Level III

NICU

Subsequent care - limited or $ 30.00/day
brief hospital care for a
NICU graduate transferred
from Level III NICU

Implemented Previously

S9660 Initial office visit for a $ 80.00

NICU graduate

Physician Fee Increase

Physician fee increases were effective July 1, 1989. The

following areas were approved for increases: Anesthesia Codes,

Audiologic Function Test, Critical Care Codes, Emergency Room
Codes, Gynecological Codes, Hospital Care Codes, Long Term Care
Codes, Neonatology Codes, Neurology and Neuromuscular Procedures,
Obstetrical Codes, Office Visit Codes, Oncology Codes, Physical
Medicine, Psychiatric Codes, Pulmonary Codes, Surgical Codes and
Vision Care Codes.

A new fee schedule will be published and distributed with the
updated Physicians* Manual.

If you have any questions, please contact your program manager at
253-6134 in Columbia.

PRO UPDATE

Physician Consultant Requirements

In order to perform peer review for Carolina Medical Review
(CMR) , a physician must:

* have an unrestricted license to practice medicine or
osteopathy in South Carolina;

* be a member of the active staff of at least one medical
care facility subject to PRO review? and

* be Board certified or Board eligible in a specialty
recognized by the American Board of Medical Specialties.

In the review process, every attempt is made not only to match
the reviewer with the specialty of the attending physician, but
also to select a reviewer from a similar hospital setting (urban
or rural) . CMR still has a need for subspecialists to

participate in the peer review process, particularly
cardiologists, cardiovascular surgeons and neurosurgeons. Any
physicians interested in performing peer review should contact
Keith H. Waters, MD, medical advisor for CMR, at 1-800-922-3089
or 731-8225 in Columbia.

ACCOUNTS RECEIVABLE

I.C. System, Inc. has prepared a "Collections Calendar" which is
a brief outline of positive business practices which you can
implement to control outstanding accounts. I. C. System, Inc.,

is the largest privately-owned debt management company in the
country and is endorsed by the SCMA. For a free copy of "The
Collector's Calendar," call Julia Brennan, SCMA headquarters, at
1-800-327-1021. For more information on I. C. System, Inc.,
call Steve Glischinski at 1-800-443-4123.

SC POLITICAL ACTION COMMITTEE

During the last two sessions of the Legislature, the SCMA dealt
with issues such as mandatory assignment, independent practice
for nurses and physical therapists, mandated health insurance
benefits for chiropractors, infectious waste, tort reform and
AIDS, just to name a few. The SCMA introduced legislation
limiting the scope of practice of chiropractors, regulation of
utilization review agencies and several insurance related bills.
Another bill of particular interest was introduced by the SCMA to
ease the licensing requirements to allow physicians, particularly
in rural areas, to practice in South Carolina. This bill passed
at the end of the 1989 legislative session.

SOCPAC helps elect and maintain friends of medicine in the
Legislature, as well as defeat opponents of organized medicine.
Next year will be an election year, and is the year that we will
elect the governor and It. governor. Full support is needed in
order to participate at an appropriate level in these elections.

If you are not a member of SOCPAC, join today by sending your
check for $100.00, payable to the SC Political Action Committee,
to SCMA, PO Box 11188, Columbia, SC 29211.

SCMA MEMBERS' INSURANCE TRUST

Are you aware that the SCMA has a health insurance plan available
to all SCMA members and their office staff?

The Members' Insurance Trust is a self-insured program,
administered by the association. All claims are paid directly
from the SCMA office. The plan is provided as a service to SCMA
members and is not for profit.

If you would like additional information, please call Julia
Brennan, Linda Nelson or Geri Galloway at the SCMA office: 798-
6207 in Columbia, or toll-free 1-800-327-1021.

UPCOMING CONFERENCES

The South Carolina Chapter of the American Academy of Pediatrics
Annual Scientific Program, "Pediatric Update," is scheduled for
August 3-6, 1989, at The Grove Park Inn, Asheville, NC. The

speakers include Frank A. Oski, MD, Johns Hopkins Children's
Center; Heinz F. Eichenwald, MD, University of Texas; and William
B. Strong, MD, Medical College of Georgia. For registration
information, contact Debbie Shealy in Columbia at 798-6207, or 1-
800-327-1021.

"The Severity and Quality Dilemma," sponsored by the SC Hospital
Association, the SC Society of Hospital Risk Management and
Quality Assurance Professionals and the SCHA Loss Control
Subcommittee, will be held August 10-11, 1989, at the Myrtle
Beach Hilton, Myrtle Beach, SC. For further information, contact
Doris Clevenger, SCHA, PO Box 6009, West Columbia, SC 29171-6009,
or 796-3080.

The South Carolina Society of Pathologists Annual Meeting is
scheduled for September 15-17, 1989, at the Mariner's Inn, Hilton
Head Island, SC. For details, contact Debbie Shealy at 798-
6207 in Columbia, or 1-800-327-1021.

The SC Commission on Aging's 13th annual Summer School of
Gerontology will be held August 6-11, 1989, at Winthrop College
in Rock Hill. The program is planned to meet the needs of a wide
variety of participants who work in the field of aging, including
practitioners, educators, agency personnel and lay persons. The
registration fee is $15.00 which must be received by July 21. An
additional $15.00 will be charged for late registrations. For
more information, call 735-0210 in Columbia.

CAPSULES

Susanne G. Black, MD, of Dillon, has been elected to a two-year
term as secretary of the SC Commission on Aging.

SCMA NEWSLETTER
is a publication of the
South Carolina Medical Association
Contributions welcomed.
Melanie Kohn, Editor
Joy Drennen, Assistant Editor
798-6207, in Columbia
1-800-327-1021, outside Columbia

MARFAN SYNDROME IN THE PARTURIENT*

M. K. BAILEY, M.D.
R. HWU-YUN, M.D.

J. D. BAKER, III, M.D
J. E. COOKE, M.D.

J. M. CONROY, M.D.

The Marfan Syndrome is an inherited disor-
der of connective tissue characterized by ab-
normalities of the cardiovascular, skeletal, and
ocular systems. Cardiovascular complications,
including aortic dilatation progressing to dis-
section and rupture, account for the 30-40%
reduction in life expectancy among those indi-
viduals. Pregnancy poses an additional stress
to patients with the Marfan Syndrome as evi-
denced in the literature by multiple reports of
fatal aortic dissection during pregnancy, labor
and delivery. The following case report de-
scribes the perioperative management of a
pregnant patient with the Marfan Syndrome.

CASE REPORT

A 20-year-old Caucasian female, G2 Pj A0
with an estimated gestational age of 39.5
weeks, was brought to the operating room for
an emergency Cesarean section because of fetal
distress. Attempted version of a frank breech
presentation earlier that day had resulted in the
onset of contractions with marked fetal tachy-
cardia and late decelerations. Past medical his-
tory was unremarkable except for known
Marfan Syndrome for which the patient had
been followed in High Risk Obstetric Clinic
since the 27th week of her pregnancy. With the
exception of frequent palpitations, symptoms
of cardiovascular involvement were minimal
with no complaints of chest pain, shortness of
breath, orthopnea, paroxysmal nocturnal
dyspnea, or edema. Medications on admission
included atenolol 25 mgs. taken QID with re-
portedly sporadic compliance. Family history
was strongly positive for the Marfan Syndrome
with the patient’s father and one sibling
affected.

Physical examination revealed a thin white

* From the Department of Anesthesiology, Medical Uni-
versity of South Carolina, 1 7 1 Ashley Avenue, Charles-
ton, S. C. 29425 (address correspondence to Dr. Bailey).

female with long lanky extremities, deformed
sternum, and pigeon chest. Marked scoliosis
was present. Head and neck exam revealed no
ocular or oropharyngeal involvement. Lungs
were clear to auscultation. Cardiac examina-
tion revealed a II/VI systolic murmur at the
apex but no definite click or gallop sounds
could be heard. Blood pressure was 1 10/70 and
pulse rate was 90 with an irregular rhythm.
Peripheral pulses were 2+ and equal in all
extremities. Abdominal examination revealed
an obvious intrauterine pregnancy with stria
but was otherwise unremarkable.

Blood chemistry values were within normal
range. The electrocardiogram showed a sinus
rhythm but with frequent multiform ectopic
beats and nonspecific ST-T wave changes.
Echocardiography performed one month prior
to admission had revealed a 49mm dilatation
of the aortic root with evidence of poor left
ventricular function. Ejection fraction was re-
corded as 3 1 % of normal. Also recorded were
signs of systolic mitral valve prolapse with
mild regurgitation but no evidence of aortic
valvular abnormality.

Upon development of fetal distress, the pa-
tient was transported with oxygen to the oper-
ating room for immediate Cesarean section
under general anesthesia. She was given Am-
picillin 2gms and Gentamicin 80mg for endo-
carditis prophylaxis. Because of the patient’s
stable prenatal course and the emergent nature
of the situation, an arterial line was not placed
prior to surgery. Rapid sequence induction
using cricoid pressure was accomplished with
curare 3mg, sodium thiopental 250mg, and
succinylcholine 1 20mg in order to protect the
patient against the hazards of pulmonary aspi-
ration. Anesthesia was maintained with 50%
nitrous oxide and .5% halothane in oxygen
prior to delivery of the baby. Sufentanil 25
micrograms was given in divided doses post

July 1989

327

MARFAN SYNDROME

delivery for additional analgesia. Pitocin lOmg
was given immediately following delivery and
an additional 20mg was added to the intra-
venous fluids for continuous administration.
The patient’s blood pressure and pulse were
stable throughout induction and maintenance
of anesthesia and at the end of the operation
she was extubated and taken to the recovery
room in satisfactory condition. The patient
was monitored with electrocardiographic te-
lemetry for three days postoperatively but
demonstrated no signs or symptoms of cardiac
decompensation. Both she and the baby were
subsequently discharged with instructions for
followup.

DISCUSSION

The Marfan Syndrome occurs in what is
termed the “classic” form in four to 10 per
100,000 persons with no sexual, racial or eth-
nic predilection. Although conclusive evi-
dence is lacking, it has long been assumed that
an inborn error of protein metabolism, specifi-
cally of collagen or elastin, accounts for the
pathologic alterations that are seen in affected
individuals.1 The pattern of inheritance is clas-
sified as autosomal dominant with variable
penetrance and therefore the actual prevalence
of the syndrome may be higher if one includes
the less “florid” cases.

There is no laboratory test available to de-
tect this disorder. Therefore the diagnosis must
be made based on clinical evidence and its
presence in other family members. The Mar-
fan phenotype has been recognized historically
by typical lesions involving the skeletal,
ocular, and cardiovascular systems. However,
more recently, dermal, pulmonary, and central
nervous systems have also been shown to ex-
hibit characteristic pathology. Multiple skel-
etal manifestations are very common, includ-
ing tall stature with dolichostenomelia, scolio-
sis, joint hyperextensibility, and anterior chest
wall deformities. Ocular abnormalities range
from myopia and flat corneas to lens subluxa-
tion and retinal detachment. Inguinal hernias
occur frequently and tend to be recurrent. Al-
though an increased incidence of spontaneous
pneumothorax has been reported, pulmonary
involvement is more commonly due to kypho-
scoliosis resulting in restrictive lung disease.

Auscultatory evidence of cardiac abnor-
malities occurs in 60% of patients and is sec-
ondary to mitral or aortic regurgitation and
mitral valve prolapse. Cystic medial necrosis
occurs in the wall of the ascending aorta lead-
ing to dilatation and aneurysm formation with
subsequent risk of aortic rupture. This makes
the Marfan Syndrome the leading cause of aor-
tic dissection in patients under 40 years old.
Unfortunately, electrocardiographic changes
are rather nonspecific, and routine chest x-rays
may remain within normal limits until aortic
dilatation is already pronounced. Echocar-
diography is far more sensitive for detection of
aortic root dilatation and has greatly improved
the diagnosis and management of these pa-
tients.

The potential aggravation of these life
threatening cardiac abnormalities by preg-
nancy is an important concern for the affected
female. Schitker and Bayer2 reviewed fatal aor-
tic aneurysmal dissection in 141 people among
whom 49 incidences occurred in women and
half of these were during pregnancy. In study-
ing 1 5 cases of fatal aortic dissection in preg-
nant patients, Sutinen and Piinoinen3 found
that nine of these cases occurred in patients
diagnosed with the Marfan Syndrome, and an
additional four patients had equivocal mani-
festations.

It has been suggested that hormonal influ-
ences during pregnancy result in the loosening
of ground substance in all body tissues4 and
that this may extend any lesion already present
in the aorta. In addition, the physiologic
changes of increased cardiac output and blood
volume during pregnancy magnify the shear
force (dp/dt) of the blood column in the great
vessels.4 Thus an increasing incidence of rup-
ture tends to parallel the normal progressive
changes occurring in the cardiovascular sys-
tem. Husebye, Wolff and Friedman5 reviewed
5 1 cases of aortic dissection with 12 dissections
occurring in the second trimester, 35 in the
third, only four during labor and seven post
partum, emphasizing the third trimester as the
most lethal period.

These previous reports focused on fatal out-
comes, but many women with the Marfan Syn-
drome are known to have had successful,
uneventful pregnancies. In a retrospective
analysis of risk determination, Pyeritz6 corn-

328

The Journal of the South Carolina Medical Association

MARFAN SYNDROME

pared three groups of patients. Groups I and II
were used as controls and consisted of (I) wives
of men with the Marfan Syndrome and (II)
mothers of sporadic “mutant” children with
the Marfan Syndrome. Group III consisted of
26 females diagnosed with the Marfan Syn-
drome. Each group was interviewed concern-
ing cardiovascular problems prior to their first
pregnancy. None of the patients in Group I
reported any problems, but two patients from
Group II recalled asymptomatic heart mur-
murs. Twelve of the Group III Marfan patients
had diagnosed abnormalities with one patient
moderately handicapped by mitral regurgita-
tion and congestive heart failure. The preva-
lence of general complications of pregnancy
such as hyperemesis, postpartum bleeding,
and back pain, as well as the prevalence of mild
cardiovascular complications, did not differ
significantly among the study groups. The only
death reported in this series was a Marfan
patient with congestive heart failure who died
shortly after pregnancy from bacterial endo-
carditis. The case report presented earlier sup-
ports Pveritz’s conclusion that the risk of death
in pregnancy is low in those patients with mild
cardiovascular involvement. However, pa-
tients with more than minimal aortic dilata-
tion, aortic regurgitation, or hemodynamicallv
significant mitral valve dysfunction are at high
risk for developing life threatening cardiovas-
cular complications during or shortly after
pregnancy.

Occasionally, definitive surgical treatment
of the patient with an aortic dissection dur-
ing pregnancy becomes necessary. Cola and
Lavin8 recently reported a case of acute aortic
dissection in a pregnant patient with the Mar-
fan Syndrome, who underwent successful aor-
tic arch replacement and coronary artery-
bypass grafting. Gott, Pyeritz, et al9 reviewed
50 patients who had undergone composite
graft repair of the ascending aorta with an 85%
survival rate at five years. Based on their find-
ings and the unfavorable natural course of the
Marfan Syndrome, these authors recommend
prophylactic repair when aortic dilatation
reaches 60mm. The success of such preventive
surgical techniques should favorably alter the
risks of pregnancy in the Marfan patient.

Pyeritz6 recommends that any woman af-

fected by the Marfan Syndrome who is consid-
ering pregnancy be examined both clinically
and by echocardiography to evaluate car-
diovascular status. He suggests that those who
have an aortic diameter less than 40mm with
minimal cardiovascular involvement be coun-
seled about the 50% genetic transmission rate
and the small, but potentially catastrophic, risk
of dissection of the aorta. These patients are
advised to complete reproduction early in life,
with emphasis on close prenatal supervision
and the need for being followed in a High Risk
Obstetric Clinic. Patients who are hemo-
dvnamically compromised or who exhibit
greater than 40mm aortic root dilatation are
advised by Pyeritz not to attempt pregnancy.
In those who do, the advisability of therapeutic
abortion becomes a consideration. Donaldson
and de Alverez recommend reserving this pro-
cedure for patients past the age of 30 who show
evidence of definite aortic disease.

Most authors recommend vaginal delivery if
possible, reserving Cesarean section for ob-
stetrical indications or for the patient with an
impending aortic dissection. If operative inter-
vention is required, these patients should be
managed so that minimal cardiovascular stress
develops. All preoperative cardiac medica-
tions should be continued up until the time of
surgery-. The extent of invasive monitoring
must be individualized according to the pa-
tient’s cardiovascular status and circum-
stances. Hypertensive changes should be anti-
cipated and controlled with appropriate drug
therapy. All patients are at risk for bacterial
endocarditis regardless of the presence of val-
vular abnormalities and, therefore, should re-
ceive prophylactic antibiotics. The increased
incidence of spontaneous pneumothorax in
these patients should be kept in mind as this
occurrence may mimic an acute cardiovascu-
lar event. Oral cavity and airway should be
thoroughly examined preoperatively since
these patients have an increased incidence of
highly arched and cleft palate, cleft lip, and
double uvula. Positioning problems, resulting
from extremes in height and skeletal abnor-
malities should also be anticipated. Postopera-
tively, these patients should be monitored
closely for signs and symptoms of cardiac
decompensation.

July 1989

329

MARFAN SYNDROME

SUMMARY

Early recognition of the Marfan Syndrome
and knowledge of its potentially lethal com-
plications facilitates successful treatment of
these individuals. It is through a joint effort by
many specialist physicians such as the obstetri-
cian, cardiologist, and anesthesiologist that
these patients can be managed safely through
pregnancy, labor, and delivery. □

REFERENCES

1. Pyeritz RE, McKusick VA: The Marfan Syndrome:
Diagnosis and management. The N Eng J of Medicine
300: 772-77, 1979.

2. Schnitker MA, Bayer CA: Dissecting aneurysms of the
aorta in young individuals, particularly in association
with pregnancy. Ann Intern Med 20: 486-511, 1944.

3. Sutinen S, Piiroinen O: Marfan Syndrome, pregnancy,

and fatal dissection of the aorta. Acta Obstet Gynecol
50: 295-300, 1971.

4. Donaldson LB, deAlverez RP: The Marfan Syndrome
and pregnancy. Am J Obstet Gynecol 92: 629-64 1,1965.

5. Husebye KO, Wolff HJ, Friedman LL: Aortic dissec-
tion in pregnancy: A case of Marfan Syndrome. Am
Heart J 55: 662-676, 1958.

6. Pyeritz RE: Maternal and fetal complications of preg-
nancy in the Marfan Syndrome. The Am J of Medicine
71: 784-789, 1981.

7. Pyeritz RE: The Marfan Syndrome. An Fam Physician
34(6): 83-94, 1986.

8. Cola LM, Lavin JP Jr.: Pregnancy complicated by the
Marfan Syndrome with aortic arch dissection, subse-
quent arch replacement and triple coronary artery by-
pass grafts. J Reprod Med 30(9): 685-8, 1985.

9. Gott VL, Pyeritz RE, Magovem GJ Jr., Cameron DE,
McKusick VA. Surgical treatment of aneurysms of the
ascending aorta in the Marfan Syndrome. Results of
composite graft repair in 50 patients. N Eng. J Med
311(17): 1070-4, 1986.

‘ SERVICE SINCE 1919”

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We have salesmen in South Carolina to serve you

We have DISPLAYED at every S.C. State Medical Society Meeting since 1921.
and advertised CONTINUOUSLY in the S.C. Journal since January 1920 issue.

330

The Journal of the South Carolina Medical Association

ERADICATION OF FILARIASIS IN SOUTH
CAROLINA: A HISTORICAL PERSPECTIVE*

WADE D. REYNOLDS, M.P.H.
FRANCISCO S. SY, M.D., Dr. P.H.**

During the late 1700’s many cases of filaria
sanguinis hominis or filaria in the blood of
man had been diagnosed and described in the
literature throughout the southeastern U. S.
with unusual frequency around Charleston,
South Carolina.1 The southeastern United
States, especially Charleston, South Carolina
and surrounding low country, has been docu-
mented as an endemic area for filariasis from
the early 1800’s. During this time one black
resident of Charleston died each year between
1855 and 1 858 of elephantiasis.2 Currently, the
vector-born diseases that were such a problem
for the United States have been eliminated
from the areas which they once ravaged. Dis-
eases such as malaria and yellow fever once
played a large role in the history of our nation,
influencing policies and events of broad scope.
South Carolina’s contribution to the under-
standing of the epidemiology of filariasis is of
interest and worthy of note for a number of
reasons. South Carolina played a major role in
understanding the epidemiology of filariasis
and demonstrated an exemplary role in the
implementation of a Charleston County vector
control program which successfully eliminated
this parasite from the Charleston environs
within a six-year period.

HISTORICAL BACKGROUND

The parasitic filarial roundworm Wucherer-
ia bancrofti, one of the causative agents of a
disease known as Elephantiasis, is the most
common of three closely related nematode
worms that are collectively termed “Lym-
phatic Filariases.” Two other species, Brugia
malayi and B. Timori, are found in more geo-

* From the Department of Epidemiology & Biostatistics,
School of Public Health, University of South Carolina,
Columbia, S.C. (Dr. Sy); the South Carolina Depart-
ment of Health & Environmental Control, Columbia,
S.C. (Mr. Reynolds).

** Address correspondence & reprint requests to Dr. Sy at
the Department of Epidemiology and Biostatistics,
School of Public Health, University of South Carolina,
Columbia, S.C. 29208.

graphically restricted areas of Indonesia and
tropical Asia. The life cycle of filariasis incor-
porates both an intermediate host (the mos-
quito) and a final human host. Infected
mosquitoes transmit the larval stage microfi-
laria to man through bites. These microfilaria
migrate to the lymphatic vessels of the host
where they mature into adult worms. Sexual
reproduction in the lymphatic vessels pro-
duces the embryos or microfilariae which are
released into the peripheral blood and are
available to infect more mosquitoes and so
complete the life-cycle. Chronic obstruction of
the lymphatic system by the adult worms may
lead to chyluria (the presence of milky appear-
ing protein in the urine) or the grotesque dis-
tension of limbs, labia or scrotum for which
the misnomer elephantiasis was coined.

W. bancrofti was first studied and shown to
be transmitted by mosquito in 1877 by Patrick
Manson while he was serving as a medical
officer to the Chinese Imperial Maritime
Customs Service in Amoy, China (one of sev-
eral Chinese “treaty ports” that was estab-
lished after the Opium War).3 Manson’s pre-
eminent work, published in 1878 and titled On
the Development of Filaria Sanquinis Homi-
nis, and On the Mosquito Considered as Host,
established the mosquito as an intermediate
host in which the development of the filarial
roundworm was seen and implicated in the
pathogenic transmission of the organism.4

Unfortunately, knowledge of mosquito en-
tomology in the 1870’s was very limited and
most mosquitos were thought to feed only once
and then die. As a result, Manson examined
only the abdomen of the mosquitos and dis-
carded the head and thorax. Both of these
events conspired to lead Manson to the er-
roneous conclusion that actual transmission
occurred “when the filaria sanguinis hominis
. . . quit its nurse mosquito” and in a free living
form was swallowed in contaminated water.
This mode of infection was widely accepted for
some 20 years until 1899 when Thomas Lane

July 1989

331

FILARIASIS

Bancroft (son of Joseph Bancroft for whom the
filarial parasite is named) suggested that trans-
mission of filaria sanguinis hominis “may gain
entrance to the human host whilst mosquitoes
bearing them are in the act of biting.”5 Thus the
most important stages of the life cycle had been
pieced together.

SOUTH CAROLINA’S ROLE

The excellent work of these investigators
was continued via epidemiological investiga-
tions in Charleston, South Carolina by several
physicians. Dr. John Guiteras, who earlier had
been treating four Cubans in Key West, Flor-
ida for filariasis, determined to study the prob-
lem in Charleston in 1886. 6 Dr. Guiteras
examined a number of patients suffering from
chyluria and other filaria related disorders.
Over a period of four years, working in con-
junction with several other physicians,
Guiteras discovered microfilaria in the blood
of some fifteen blacks and seven whites.7

These findings, and the continuing man-
ifestations of elephantiasis in the city of
Charleston and immediate surrounding area,
spurred an investigation by Dr. Francis B.
Johnson, who at the time was Professor of
Pathology at the Medical College at Charles-
ton. Dr. Johnson conducted a larger scale sta-
tistical survey in Charleston in order to
discover the extent of the problem.8 Dr. John-
son’s work which was completed in 1914 and
published in 1915 reported that 19.25% of a
survey of 400 patients admitted for all causes
to Roper Hospital had blood smears that har-
bored microfilaria. This rate is roughly com-
parable to the rates found by studies performed
during the same time period in parts of Africa,
Puerto Rico and Lagos of West Africa.9 Dr.
Johnson also conducted a poll of 50 local phy-
sicians in the Charleston area and asked them
“What is the total number of cases of filariasis
you have seen during your entire practice?”
The reported results were 494 cases. However,
the surveyed physicians also reported 244
cases of chyluria, 2 1 3 elephantiasis, eight both
elephantiasis and chyluria and four other. The
study also pointed out that some overlap of
reporting could occur. These two studies
served to elicit the interest of another re-
searcher, Dr. Edward Francis, an officer of the
United States Public Health Service. A year

later (in 1915) Dr. Francis conducted a similar
study of Charleston’s “Old Folks Home”
which examined 37 residents and found 13 or
35% of the study group had microfilaria in
their blood. 10 Again in 1 9 1 7 Dr. Francis under-
took a study of nine southern towns with mos-
quito species and environmental conditions
similar to Charleston to discover if there were
any other endemic foci of filariasis in the
U. S. 1 1 His results showed that only nine of the
1,470 surveyed individuals were positive for
microfilaria in their blood, and these nine indi-
viduals had histories of having lived in en-
demic areas such as Cuba or Charleston. These
results and other published studies from the
same time period indicate that Charleston was
the only documented endemic focus on the
North American continent at that time. Dr.
Francis’s report and recommendations for pre-
vention of filariasis as published in 1919 were
immediately put into effect by the Charleston
City Health Department.12

The city had undertaken the construction of
a municipal water supply which was com-
pleted around 1903. However, many citizens
resisted using water from this supply, com-
plaining of “difficulty in getting proper laun-
dering done and washing their hair.” During
construction of the municipal water supply,
citizens complained loudly of the inconve-
nience and the “miasmas” thought to be re-
leased by the freshly turned earth.13 It might be
interesting to note here, that a local surgeon
sought to halt construction of the project due to
the public hazards presented by the large
amounts of freshly turned earth the construc-
tion would produce and filed suit against the
City Health Department. The case was even-
tually settled out of court when the city agreed
to spread large amounts of chloride of lime
(calcium chloride, a commonly used disinfec-
tant at that time), sprinkling the white powder
over the freshly turned earth. As the project
continued, the City Health Department’s bud-
get was strained by the necessity of buying such
large amounts of disinfectant. The problem
was alleviated by resourcefully substituting re-
labeled bags of spoiled flour obtained from a
local mill for the similar appearing disinfec-
tant. No further complaints arose from the
incident.14

The Charleston Board of Health, with Dr.

332

The Journal of the South Carolina Medical Association

FILARIASIS

Leon Banov acting as city health officer, re-
viewed the work done by Dr. Johnson and Dr.
Francis. Working in close cooperation with
them, the department launched a detailed
study of some of the positive filaria carriers.
The study revealed that cases were more nu-
merous in the northeastern portion of the
city.15

The historical record seems to indicate that
the concerted efforts of the U. S. Public Health
Service and the intuitive investigative skills of
Dr. F. B. Johnson helped Public Health Offi-
cials to better understand the epidemiological
nature of the parasite and to disrupt its trans-
mission cycle. The City Health Department,
armed with the knowledge gleaned from these

studies, launched a “vigorous campaign” city-
wide that required by law the eradication of
any potential mosquito-breeding containers
and actually sent workers from site to site,
directing them to fill in the large numbers of
cisterns, rain barrels and other water con-
tainers.16 The program was so successful that
approximately six years later in 1 926, when the
Mexican government sent an official Public
Health Office Delegation to study Charleston’s
filariasis situation, they were unable to dis-
cover a single case despite the attempt to follow
up on the records of previously known cases
and carriers (See Figure l).17

CHARLESTON, S.C. &
NEAREST ENDEMIC AREA (PUERTO RICO)
MICROFILAREMIA PREVALENCE RATES

(1880-1930)

YEAR

FIGURE 1. Prevalence rates of Charleston, S. C. and nearest endemic area (Puerto Rico), as reconstructed from two
published local prevalence surveys (see Johnson and Ashford n.9) and a conservative estimate in 1890 drawn from cumulative
documented cases and studies reported during that time period (1880-1900). The vertical dashed line indicates the enactment
of the city’s vector control program in 1919.

July 1989

333

FILARIASIS

DISCUSSION

Apparently the establishment of Charleston
as an endemic focus of filariasis was its geo-
graphic location and Charleston’s role as a port
with close trade ties with the West Indies. The
islands of Barbados, Puerto Rico, Cuba and
other islands of the West Indies were known to
have been endemic for filariasis through the
slave trade up until 1 804 at which time slaves
ceased to be imported. The presence of fil-
ariasis on the island of Barbados has been
documented from about 170418 and led to the
euphemism of “Barbados leg” as a local slang
term for the malady. Undoubtedly sometime
around the 10-20 years following the cessation
of the slave trade in 1 804 the high concentra-
tions of slaves introduced to the area served as
a reservoir of infection for an area containing a
large susceptible population and a number of
capable and efficient vectors.

The carrier mosquito Culex fatigans was
and is abundant in the Southeastern United
States. The Anopheles and Aedes species of
mosquitoes are also known vectors for W.
bancrofti and are present in the low country of
South Carolina currently. It should be pointed
out, however, that the vector control pro-
gram’s primary focus was to reduce the num-
bers of potential vectors in contact with high
concentrations of people, thereby reducing the
risk of multiple bites from an infected vector to
a susceptible host.

The historical record is far from complete
regarding the eradication of filariasis from
Charleston, South Carolina. Dr. Eli Chernin, a
recognized authority on the historical aspects
of filarial research, points out the lack of docu-
mentation of a mosquito control campaign in
official city public health records from the
years 1920- 1926. 19 Dr. Chernin goes on to con-
clude that “Circumstantial evidence links the
developing sewerage and water systems with
the disappearance of filariasis from Charles-
ton.” It is the position of the authors of this
paper that the development of Charleston’s
water and sewerage system played a contribut-
ing role in the elimination of filariasis. An
aggressive mosquito control campaign was
waged and directed against all the vector-born
diseases of the time (mainly malaria, filariasis
and yellow fever) and ultimately resulted in the
final elimination of filariasis from Charleston

and its environs.

This conclusion was reached upon consider-
ation of additional historical records authored
by Dr. Leon Banov in his memoirs, As I Recall,
and reiterated in a personal letter by Dr. Banov
to Dr. Paul C. Beaver of Tulane University in
1969. In this document, Dr. Beaver specifically
requested information on the disappearance of
filariasis from Charleston. Dr. Banov, who
served as city health officer from around 1912,
states that a mosquito control campaign was
“immediately launched” upon review of John-
son’s findings. Additional evidence for the ex-
istence of a mosquito control campaign that
targeted filariasis is the presence of an epi-
demiological map in the historical files of Dr.
Johnson and stored exclusively with filarial
related materials. Unfortunately, although the
map is indirectly referenced by Banov, it con-
tains no date or internal indication of its use.

Dr. Johnson’s work was published in 1915.
Dr. Francis’s work was published in 1 9 1 9. Dur-
ing the interim time span (1918), a consulting
visit was paid by Joseph A. LePrince, a re-
spected sanitarian of the times. Ostensibly, the
city of Charleston and U. S. Public Health Ser-
vice’s program aimed at anopheline malaria
vector control, mentioned in the city records of
191 8, 20 was expanded to include the elimina-
tion of filariasis. This would account for the
lack of documentation of a program directed
specifically towards filariasis in official public
health records. It would appear unlikely that
the elimination of filariasis was due ex-
clusively to the establishment of permanent
water and sewerage systems, although these
systems played a contributing role. The rec-
ords indicate a more aggressive campaign di-
rected toward vector control was waged and
won in a reasonably short period of time (six
years).

Current research indicates that once reinfec-
tion is eliminated, even chronic disease can be
reversible. Reports of individuals becoming
amicrofilaremic in as short as three months
time after moving from an endemic area have
been recorded.21 These studies would corrobo-
rate the reports of the rapid disappearance of
filariasis form Charleston as reported by
Banov.

The role South Carolina’s physicians played
in the understanding and elimination of fil-

334

The Journal of the South Carolina Medical Association

FILARIASIS

ariasis in Charleston serves as a lasting tribute
to their diligence and thoroughness. The con-
tributions of Dr. Johnson and Dr. Banov, in
conjunction with the efforts of the U. S. Public
Health Service’s Dr. Francis, to the general
welfare of the citizens of South Carolina as a
whole has long since been accomplished, but
can still be appreciated. □

ACKNOWLEDGMENT

The authors gratefully acknowledge the professional
acumen of Anne Donato and Elizabeth Newsom, Refer-
ence Librarians of the Waring Historical Library, for their
generous assistance.

REFERENCES

1 . Bernard Romans, A Concise Natural History of East
and West Florida. New York, 1775; reprinted, New
Orleans, pp. 170-171, 1961.

2. JL Dawson, “Return of Deaths in the City of Charles-
ton,” Charleston Med. J. Rev., 10:747, 1855; 11:574,
1856; 13:282, 1858; 14:138, 1859.

3. Eli Chemin, “Sir Patrick Manson’s Studies on the
Transmission and Biology of Filariasis,” Reviews of
Infectious Disease 5:( 1)1 48-1 49, 1983.

4. Patrick Manson, “On the development of the Filaria
Sanquinis Hominis, and on the Mosquito Considered
as a Nurse.” Journal of the Linnean Society of London
[Zoology] 14:304-311, 1878.

5. TL Bancroft, “On the Metamorphosis of the Young
Form of the Filaria bancroftif Journal of Tropical
Medicine, 2:91-94, 1899.

6. Todd L. Savitt, “Filariasis in the United States,” Jour-
nal of the History of Medicine and Allied Sciences,

32(2), 140-150, 1977.

7. John Guiteras, “The filaria sanquinis hominis in the
United States; Chyluria,” Medical News, Phila.
48:399-402, 1886.

8. F.B. Johnson, “Filarial Infection — An Investigation of
It’s Prevalence in Charleston, South Carolina,” South-
ern Medical Journal, 8:630-635, 1915.

9. Foran Jr., Tropical Medicine & Hyg., Feb. 25, 1910;
Connal, Jr., Tropical Medicine & Hyg., Jan. 1, 1912;
Ashford, Medical Record, p. 724, 1903 as quoted by
Johnson (n.8).

10. Edward Francis, “Filariasis in the Southern United
States,” Hy genic Lab. Bulletin, 117:17-19, 1919.

11. Ibid.

12. Leon Banov, Letter by Dr. Banov [Charleston, Oct. 21
1969, to Paul C. Beaver Ph.D. Prof, of Trop. Dis. &
Hyg, Tulane Univ.] Waring Historical Library,
Charleston, SC.

13. Leon Banov, As I Recall; The Story of the Charleston
County Health Dept. (R. L. Bryan, 1970, page 9).

14. Leon Banov, Ibid.

15. Leon Banov, (n.13) page 56 and (n.12).

16. Leon Banov, (n. 12).

17. Ibid.

1 8. James A. Gorden, “Elephantiasis — Its History, Symp-
tomology, Aetiology and Pathology, with a Report of a
Case and Successful Treatment.” Southern Medical
Journal, 6:65-80, 1850.

1 9. Eli Chemin, “The Disappearance of Bancroftian Fil-
ariasis from Charleston, South Carolina,” American
Journal of Tropical Medicine and Hygiene, 37(1),
111-114, 1987.

20. Year Book, City of Charleston, South Carolina, 1918,

p. 161.

21. Felix Partono, “Filariasis in Indonesia: Clinical Man-
ifestations and Basic Concepts of Treatment and Con-
trol,” Trans R Soc Trop Med & Hyg, 78:9-12, 1984.

July 1989

335

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336

The Journal of the South Carolina Medical Association

THE ANNUAL MEETING OF THE AMA

REPORT OF THE SCMA DELEGATION

JOHN C. HAWK, JR., M.D*

Many persons not in the know must have wondered what was going on
in Chicago (June 18-22, 1989) when they saw so many physicians
wearing shiny buttons with a strange inscription: ET's in big
letters, with (RATIONING) in smaller letters below, and over it
all a red outer circle and an oblique slash, the international
negative road signal, in this case meaning STOP OR HALT. The
buttons certainly did not refer to the celebrated movie or to its
lovable central character. Instead, they referred to the latest
Cost Containment measure proposed in Congress, so-called
Expenditure Targets. There is nothing lovable about Expenditure
Targets for either patients or physicians. Almost certainly they
will lead to Expenditure CAPS, which are essentially synonymous
with Rationing.

At the time the House of Delegates was meeting, the U. S. House
of Representatives Ways and Means Health Subcommittee, chaired by
Rep. Fortney (Pete) Stark, was proposing its version of an
Expenditure Target bill, which took into consideration some of
the proposals from the Physician Payment Review Commission
( PPRC ) . The House of Delegates was supplied with information as
it developed, and an overall plan of action implemented. This
included two direct telephone lines to Congress, for delegates to
call their representatives about the matter, and the availability
of copies of the prepared statements which had been made by the
AMA to the subcommittee. We were also given copies of posters,
which are similar to advertisements being placed in national
magazines. One of these depicted an elderly woman, obviously in
some distress, with the notation, "How do you tell a Medicare
patient that she is an Expenditure Target?" By the time this
report is printed, further action will probably have occurred.
Some developments were reported in the AM News of June 2 3/3 0.
Full and detailed reports of the House of Delegates meeting will
be published in the two ensuing issues of the AM News and you
are urged to read these carefully, to keep properly informed.

On the House floor on Wednesday, over an hour was expended in
discussing the entire subject of Expenditure Targets, which
included the Report from the Board of Trustees and four
resolutions. Three of the resolutions were extracted for
separate discussion, and a number of substitute resolutions
proposed. Resolution 87 from Virginia, which resolved "that the
AMA vigorously oppose the concept of Expenditure Targets in the
Medicare program or any other action which would lead to the
rationing of or reduce access to medical care," was adopted.

*30 Bee Street, Charleston, S. C. 29403.

Substitute Resolution 200 was also adopted, reaffirming the AMA's
willingness to participate in efforts to control the cost of
Medicare in a manner that preserves the quality and availability
of health care to Medicare recipients. It further reaffirmed the
AMA's position that the Medicare program should establish
actuarily sound financing of benefits as stated in Board of
Trustees Report MM (A-86) and further urged Congress to
incorporate the following considerations when applying budgetary
controls to Medicare, in place of Expenditure Targets:

A. Assure a high priority to health care for Medicare
patients in relation to other programs when allocating federal
funds .

B. Given Medicare's financial resources, develop a
mechanism to channel these resources to those patients with
greater financial need and to require a proportionately larger
financial contribution by the more affluent toward their own
health care, and finally reduce the cost of defensive medicine
(approximately $20 billion per year) caused by the present tort
system.

OVERVIEW

The House considered an enormous amount of business, undoubtedly
the greatest volume ever faced by the Delegates. By the third
day, 435 (100%) of the 435 accredited delegates had been
registered. These included delegates from two new specialty
societies, which were accepted by the House: the American
Society of Hematology and the Association of University
Radiologists. The Society of Head and Neck Surgeons was not
granted representation in the House of Delegates. Of the 435
total delegates, 347 represent state associations.

ADDRESSES TO THE HOUSE

Dr. Louis W. Sullivan, newly appointed Secretary of Health and
Human Services, addressed the House at the opening session on
June 18. Dr. Sullivan has been an active member of the Medical
Association of Georgia. He started out by saying, "I am here to
tell you that Marcus Welby is dead. The long honeymoon of the
American public and the kindly physician is over." He pointed
out a number of the problems in this country with the common
thread of poverty running through many related to health. He
stated that the Administration strongly supports a three-part
framework for physician payment reform, including a resource
based fee schedule, an expenditure target for Medicare physician
services, and beneficiary protections. He outlined part of the
agenda of the Administration. He challenged the AMA to
participate in the "reformation of the American health care
system as we know it today." Certainly much that he said was not
encouraging to physicians, but at least he does seem to
understand the problems of medicine.

Dr. James E. Davis, outgoing president, gave a splendid address
entitled, "A Symphony of Service to American Medicine." It will
undoubtedly be published in JAMA and should be read by all.

Dr. Alan R. Nelson, in his Inaugural Address as the 144th
president of the AMA, took as his title, "Humanism and the Art of
Medicine: Our Commitment to Care." He spoke of four aspects of
the art of medicine, including (1) humanism with its values of
compassion and understanding, (2) diligence and faithfulness, (3)
altruism and (4) ethical behavior. He ended with the following:
"The art of medicine is that quality makes the doctor more than
just a scientist. It is that quality that is cherished by those
who serve. It provides the bond between the patient and
physician that will make medicine a career of satisfaction and
fulfillment as we bring to bear, for our patients, the wonders of
science now and through succeeding generations of men and women
proud to be called 'doctor'."

SCMA RESOLUTIONS

The SCMA delegation introduced two important resolutions:
Resolution 97 asked that the AMA request immediate action by the
HCFA, and if necessary by Congress, to withdraw the requirement
for inclusion of the referring physician's identification number
on Medicare claims of radiologists, pathologists, independent
laboratories and other physicians when a patient was referred by
another physician for consultation or treatment. As all
physicians are aware, in South Carolina this identification
number must be the social security number of the referring
physician, and obtaining this may entail considerable difficulty
and delay. The Reference Committee recommended that Resolution
97 be referred to the Board of Trustees for action, which would
have given the Board the option of deciding what to do with it.
Dr. Dan Brake, who as president of the association was sitting as
an alternate delegate, spoke eloquently about the problems
involved. Immediately thereafter, acting upon a motion made by
the Pennsylvania Delegation, the House voted to adopt the
resolution, which, of course, was a much stronger action.

Resolution 96 pointed out that Section 1801 of PL 89-97, the
original Medicare Law, 1965, has never been repealed or revoked,
and that it states nothing in this title should be construed to
authorize any Federal officer or employee to exercise any
supervision or control over the practice of medicine or the
manner in which medical services are provided. ..." Our
resolution called upon the AMA to examine the subsequent acts of
Congress and the regulations promulgated by governmental agencies
under these laws which impose onerous burdens on physicians in
their care of Medicare patients, to determine whether such acts
or regulations are in violation of Section 1801, and furthermore
to take whatever legal action is feasible to prevent
implementation and/or enforcement of such laws or regulations.
The Reference Committee recommended referral to the Board for
action. We requested that this resolution be adopted rather than

referred, but after EVP Dr. James Sammons spoke of the Board's
concern about the number of laws that would have to be studied,
and the potential costs, the House voted to accept the Reference
Committee's recommendation for referral to the Board of Trustees
for action. We will, of course, receive a report as to what is
done.

CANADIAN HEALTH CARE SYSTEM

Responding to Resolution 124, A-88, the Board presented Report V
which gave a detailed evaluation of the Canadian Health Care
System and outlined why it is not suitable for application in the
United States. This report was adopted by the House.

In addition, the House adopted amended Resolution 127 stating,
"Resolved, that the AMA recognize the Canadian Compulsory Health
System to be a system of socialized medicine managed by an ever
enlarging and more expensive bureaucracy, financed by ever
increasing taxation and featuring rationing, shortages, health
care waiting lists and an absence of private sector alternatives,
and further be it Resolved, that the AMA document and publish the
truth about the deficiencies and problems that characterize
Canadian health care."

PHYSICIAN PAYMENT UNDER MEDICARE -RBRVS

Report NN of the Board of Trustees, Physician Payment Under
Medicare: Resource Based Relative Value Scale for Physician
Services, and Report BBB of the Board, Development and
Implementation of a new Medicare Payment System, were considered
together with two resolutions. This subject naturally evoked a
great deal of discussion and debate. The final recommendations
are of such sufficient importance that I will quote them
completely:

1. That the AMA reaffirm its support for development and
implementation of a Medicare indemnity payment schedule according
to the policies established in Board of Trustees Report AA (I-
88) ;

2 . That the association support reasonable attempts to
remedy geographic Medicare physician payment inequities that do
not substantially interfere with the AMA's general support for an
RBRVS-based indemnity payment system;

3 . That the association continue to work to ensure that
implementation of an RBRVS-based Medicare payment schedule occurs
upon the expansion, correction and refinement of the Harvard
RBRVS study and data as called for in Board Report AA (1-88) , and
upon AMA review and approval of the relevant proposed enabling
legislation;

4. That the association oppose any effort to link the
acceptance of an RBRVS with any proposal that is counter to AMA

policy, such as expenditure targets or mandatory assignment?

5. That the AMA continue to oppose the arbitrary and
unwarranted use of co-called "overpriced procedure" reductions as
part of the fiscal year 1990 budgetary process, the use of data
generated by the yet-to-be-completed Harvard RBRVS study to
determine such payment cuts, and especially, the use for this
purpose of RBRVS data for specialties whose RBRVS results are
being restudied as part of Phase II of the RBRVS study;

6. That in the event Congress decides to act on physician
payment reform in the interval between meetings of the House of
Delegates, the House believes that the Board of Trustees will
exercise its responsibilities to act with prudence and
leadership in seeking the best possible result for medicine,
consistent with principles embodied in Board Report AA (A-88) ;

7. If the federal government chooses to reduce
reimbursement for certain "targeted procedures," the AMA lobby
strongly to limit such reductions to geographic areas where
current reimbursement exceeds the mean national reimbursement for
that procedure.

Also adopted was the final resolve from Resolution 22 3 from the
Hospital Medical Staff Section which states: "Resolved, that the
AMA develop and aggressively seek Congressional sponsorship and
support for federal legislation that will allow AMA and the state
medical associations, on behalf of physicians, to negotiate
payment schedules on federal and state policies respectively,
impacting on physician reimbursement.

COVERING THE UNINSURED

In Report JJ, the Board gave a detailed report about the problem
of providing medical care to the uninsured. Here again there was
much discussion, and finally passage of two substitute or amended
resolutions as follows:

1. That the AMA endorse the concept of a phased in
requirement that employers (limited initially to large employers)
provide health insurance coverage within the private sector for
all full-time employees, with coverage expanding over several
years and with a program of diminishing tax credits or other
incentives to avoid adverse effects on employers.

2. That the AMA continue to study all approaches to
providing health services for the uninsured and work with
business groups to develop approaches that are best suited to the
needs of small employers.

PARTICIPATING/NON-PARTICIPATING PHYSICIANS

The House passed a substitute resolution that stated, "Resolved,
that the American Medical Association seek to remove, on the

explanation of Medicare benefits sent to the patients of Medicare
non-participating physicians, all statements regarding the
participation status of the physician and the alleged benefits
associated with the assignment of claims from seeing a
participating physician."

In addition, a resolution from the Hospital Medical Staff Section
was adopted which states, "Resolved, that the American Medical
Association seek legislation which requires all third party
payors including Medicare to explain to their potential and
current beneficiaries, in clear and simple terms, those medical
services and procedures which they (third party payors) will and
will not cover; and further Resolved, that the AMA seek
legislation that requires all third party payors including
Medicare to provide an easily understandable payment schedule to
their potential and current beneficiaries; and be it further,
Resolved, that the AMA vigorously resist any attempt to directly,
indirectly or surreptitiously shift the responsibility for
explanation of policy benefits to physicians and finally
Resolved, that the American Medical Association petition
Congress, the Health Care Financing Administration (HCFA) and
Part B carriers to remove all factors that discriminate against
non-participating physicians in Medicare."

PHYSICIANS' INVOLVEMENT IN COMMERCIAL VENTURES

Report ZZ from the Board of Trustees gave a detailed analysis of
the current status of legislation, particularly that promulgated
by Representative Fortney (Pete) Stark in February 1989, relating
to prohibitions against referral of patients by physicians to
facilities in which they have a financial interest. The so
called "safe harbors" for certain financial arrangements were
outlined, together with recommendations for advisory opinions by
the Office of Inspector General, and an approach to a transition
period while any new legislative standards are being developed.
This report was adopted in lieu of three resolutions considered
also by the Reference Committee.

PRO AND QUALITY CARE ISSUES

A total of 21 resolutions dealt with various aspects of the PROs,
quality care issues, practice parameters, etc., and were
considered in detail in Reference Committee G, together with
three reports from the Council on Medical Service and three
reports from the Board of Trustees. The recommendations adopted
are complex but include that the AMA seek withdrawal of the
proposed model letter notifying the beneficiary of quality of
care denials. Also, if adequate due process considerations are
not provided in any final Substandard Quality Care regulations,
that the AMA use all available options, including legal action,
to prevent further implementation until said considerations are
addressed, and furthermore that quality care decisions be made by
identifiable PRO physician reviewers based on their clinical
experience and judgment rather than reliance on mandated written

criteria. This is a constantly changing field and will require
careful attention by all physicians to actions and events
reported in various AMA publications.

OTHER IMPORTANT ITEMS

Since it is obviously impossible to cover all of the items
discussed by the House of Delegates, all physicians are urged to
peruse carefully the various articles in the AM News reporting on
the Annual Meeting. I will mention briefly a few of the actions
taken:

* Adopted a resolution that the AMA, through its coalition
with business and industry and its state federations, give
priority attention to a partial and rational deregulation of the
insurance industry in order to expand access to affordable health
care coverage, and further that the AMA reaffirm its commitment
to private health care insurance using pluralistic, free
enterprise mechanisms rather than government mandated and
controlled programs.

* Adopted a related resolution that the AMA vigorously
pursue the passage of existing AMA draft legislation that will
develop mechanisms and guidelines by which states that develop
programs to cover health care for the uninsured and underinsured
will be able to gain participation by ERISA exemption in the
funding for their plans.

* Referred for action a resolution that the AMA support
alternatives to mandated government control plans, such as repeal
and removal of many costly state government health insurance
regulations, giving individual tax reductions for health
insurance premiums and restoring full deductibility of Individual
Retirement Accounts.

* Referred for action a resolution that the AMA vigorously
oppose any federal legislation that would mandate Medicare
assignment; and at the same time continue to stress our belief in
checking the patient* s financial ability to pay.

* Adopted a resolution that the AMA advocate and support
the restoration of the deductibility of Individual Retirement
Account (IRA) contributions of up to $2,000 each year for all
workers, and further that the AMA support legislation which would
expand the $2,000 deduction for spouses and in addition allow
workers to use their IRA funds to purchase health and long term
care insurance without tax or other penalty.

* Reaffirmed its established policy regarding a smoke free
society, with the addition of advocating that all American
hospitals ban tobacco use by January 1, 1991, that physicians
prohibit smoking and use of tobacco products in their offices,
and that the AMA work towards legislation and policies promoting
a ban on smoking and use of tobacco products in hospitals, health

care institutions and educational institutions.

* Adopted a resolution asking appropriate AMA efforts to
cause governmental agencies and Medicare insurance carriers to
discontinue the use of the term, "medically necessary services,"
and instead use the more appropriate and accurate term, "non-
covered medical services," and convey this information also to
members of Congress.

MEMBERSHIP AND DUES

In Report P, the Board of Trustees gave considerable information
about the impact of the AMA Direct Membership Option (DMO) ,
adopted in 1981, on total AMA membership and also on state and
county medical society membership. The data demonstrated that
there has been no adverse impact on state membership from the
DMO. The Board also reported on actions taken to increase
student membership.

In regard to dues, the Board recommended that no change be made
in dues level for 1990. It should be noted that if membership
recruitment at the county, state and AMA levels could be
increased appropriately, it is likely that further dues increases
in the foreseeable future would not be necessary at any level of
organized medicine. The obvious problem is that there are many
physicians who still do not belong, and yet reap many of the
benefits of these organizations, especially in the political
arena and relative to third party payors. Prior to this meeting
I received several phone calls and other direct communications
from physicians asking me to push for implementation of the
RBRVS . Several of these were from persons who are not members of
the AMA. I pointed out to them that if they and thousands of
others would join the AMA, so as to give the AMA a larger
constituency, the AMA could be more much effective in its efforts
in protecting the rights of physicians and patients.

SCMA DELEGATION

The SCMA delegation to the AMA included Randy Smoak, Don Kilgore,
and John Hawk, delegates; Gavin Appleby, Charlie Duncan and Walt
Roberts, alternate delegates? Dan Brake, president; Chris Hawk,
chairman of the board? Roger Gaddy, Steven Hulecki, delegate and
alternate delegate to the Young Physicians Section; Mark Milburn,
Melissa McClure and Tom Phillipakis, medical students? Bill Mahon
and Barbara Whittaker, staff. The delegation worked diligently
and we hope effectively.

We again express our appreciation for the opportunity to
represent the SCMA. We invite all South Carolina physicians to
join both the SCM and AMA, to give us their input, and to join
with us at any future House of Delegates* meetings.

Editorial

TICKS, TETRACYCLINE, AND BACKYARD TERRORISM

In 1873, a settler to the Bitterroot Valley of
western Montana died of an unusual case of
“black measles.” In 1972, some citizens of Old
Lyme, Connecticut, complained that their
joints hurt. It now seems ironic that our two
most important tick borne diseases — Rocky
Mountain spotted fever (RMSF) and Lyme
borreliosis — took their names from such his-
torical accidents. We have known for years
that RMSF occurs mainly in the Southeast, not
the Rockies. Now, front-cover news stories tell
us that Lyme disease has appeared in all but
seven of the 50 states.1 Still, why worry much
in South Carolina? According to official
DHEC reports, only 23 cases of RMSF and 10
of Lyme disease occurred within our borders
during all of 1988.

In this issue of The Journal, Stanley Schu-
man and Samuel Caldwell dispel any basis for
complacency. These investigators from the
Agromedicine Program at MUSC surveyed
2,346 primary care physicians (a 57% response
rate) and found 344 cases of RMSF and 90 of
Lyme disease during, the same 12-month pe-
riod. The implications: (1) tick borne diseases
are in fact a major public health problem in the
Palmetto State; and (2) there is widespread
under-reporting of reportable diseases.

If the past is truly prologue, then we should
also heed the historical paper in this issue by
Wade Reynolds and Francisco Sy. Earlier in
this century, it was widely known that the
Charleston area contained a focus of filariasis
(elephantiasis). However, the full extent of the
problem was not clearly defined until Dr. Fran-
cis B. Johnson of what is now MUSC (then the
Medical College of South Carolina) polled 50
local physicians with this question: “What is
the total number of cases of filariasis you have
seen during your entire practice?” Johnson de-
termined that filariasis was not merely en-
demic in the Charleston area; it was hyper en-

demic. These data prompted public health offi-
cials such as Dr. Leon Banov to spring into
action. Filariasis became a memory.

Future historians are likely to regard the new
survey of Schuman and Caldwell, like the old
one by Johnson, as something of a turning
point. However, one caveat about such ques-
tionnaire surveys is the problem of case ver-
ification. How can we be sure that most of the
patients actually had RMSF or Lyme disease,
especially in today’s era of widespread antibi-
otic therapy for presumptive diagnoses?

RMSF and Lyme disease are radically differ-
ent diseases — one acute and life-threatening,
the other chronic and disabling; one caused by
a rickettsial organism, the other by a spiro-
chete. From the perspective of diagnosis, how-
ever, they share four features:

( 1 ) Precise diagnosis by demonstration of
the organism is technically possible but is
available in only a few laboratories.

(2) Strong presumptive diagnosis de-
pends upon the presence of a near-diagnostic
rash, but the disease can occur without the
rash. The red macules of RMSF, beginning
on the extremities and spreading centripet-
ally, never appear in up to 1 6% of cases. The
expanding, ring-like plaque with central
clearing (erythema chronicum) of Lyme dis-
ease never appears in up to 25% of victims —
and possibly a greater percentage, since this
marker has been used to a large extent for
case-definition.2

(3) Serologic tests are available, but are
fraught with problems of interpretation. In
both diseases, sequential specimens may be
necessary; in neither disease does there seem
to be clear-cut agreement about the true sen-
sitivity and specificity of the available
methods.

(4) Fear of missing treatable disease,
combined with growing public awareness,

July 1989

341

places strong pressure on physicians to treat

on the basis of presumptive diagnoses.

Let us briefly review the latter problem.

In the case of RMSF, the pressure to pre-
scribe tetracycline (or doxycycline or chloram-
phenicol) arises from the 20 to 30 percent case-
fatality rate without treatment. Two deaths
occurred in South Carolina during 1988. To-
day, it has been noted, “a death from Rocky
Mountain spotted fever is likely to leave the
legacy of a lawsuit.”3 Unfortunately, some
deaths will occur despite the best management
on account of delays in seeking care and on
account of what statisticians call “outliers”
(that is, atypical presentations defying our al-
gorithmic approaches to clinical problems).
The constellation of fever, rash, severe head-
ache, and history of tick exposure makes a tight
case for early treatment. However, even in
highly endemic areas it has been shown that
only 4 1 % of patients were given a correct diag-
nosis on the first visit.4 The problem becomes
how to define when to treat, and when to ob-
serve expectantly, in less-than-classic cases.
One might err toward treatment for older pa-
tients and for those with “the worst headache
I’ve ever had.” For other patients — those with
seemingly benign “viral illness” during all but
the winter months — one should strongly en-
courage a return office visit in the event of
persistent fever (longer than three days) or new
symptoms. The problem could, of course, be
something other that RMSF — such as endo-
carditis.

In the case of Lyme disease, the pressure to
treat arises mainly from the late complications.
Lyke syphilis, Lyme disease is a three-stage
spirochetal disease capable of masquerading
under many guises (Table).5 Tetracycline is
currently the drug of choice for the primary
(stage I) manifestations. Patients receiving
tetracycline (and to a lesser extent, patients
treated with penicillin) are less likely to de-
velop late complications. Treatment of the late
complications of Lyme disease (stages II and
III), many of which appear to be immu-
nologically-mediated,6 is problematic. Mount-
ing evidence suggests that ceftriaxone (Ro-
cephin), two grams daily for a prolonged
course, is more effective than high-dose pen-
icillin G.7 Ceftriaxone must be given parent-
erally and is quite expensive — gram-for-gram,

a caviar even among third-generation cephalo-
sporins. When, therefore, should ceftriaxone
be prescribed for symptoms that might be
Lyme disease — but without a clear history of
erythema chronicum? Again, such therapy
might mask the true diagnosis.

All around the country, “Lyme support
groups” are springing up to discuss the protean
and debilitating manifestations of this still-
emerging disease concept. Lyme disease now
joins the Epstein-Barr virus as a possible but
difficult-to-prove cause of the chronic fatigue

TABLE

The Three Stages of Lyme Disease

STAGE I (following tick bite which is often

unrecognized, and lasting a median of four weeks):

CUTANEOUS: Erythema migrans — a unique skin
lesion consisting of expanding, ring-like plaque
with a red border and a pale-indurated center
(can be single or multiple); a variety of less-
specific rashes also occur.

FLU-LIKE SYNDROME: Variable presence of
low-grade fever, chills, malaise, fatigue,
headache, photophobia, dysesthesias, stiff neck,
migratory arthralgias, and other symptoms.

STAGE II (after a latent period of well-being following

Stage I):

NERVOUS SYSTEM (15%): Headache with

evidence of meningeal irritation; neuritis (often
with unilateral or bilateral Bell’s palsy); subtle
manifestations of encephalitis such as sleep
disturbance and poor concentration; a wide
spectrum of other reported problems including
mononueuritis multiplex, transverse myelitis,
and pseudotumor cerebri.

CARDIAC (8%); heart block and other rhythm
disturbances; myocarditis, syncope, dizziness,
dyspnea, substemal pain.

EYE: Conjunctivitis; occasionally panophthalmitis

STAGE III (weeks, months, or years later):

ARTHRITIS (60%): recurrent monarticular or
asymmetric pauciarticular arthritis mainly
affecting large joints; less often a seronegative,
rheumatoid-like arthritis affecting small and large
joints; predilection for the knees; progression to
chronic arthritis in about 10% of patients.

CENTRAL NERVOUS SYSTEM: multiple
sclerosis-like demyelinating illness; psychiatric
disorders (primarily in children); episodic,
incapacitating fatigue syndrome.

342

The Journal of the South Carolina Medical Association

syndrome. Patients are demanding “the test."
Unfortunately, serologic testing for Lyme dis-
ease reminds us of the cruel lesson of Bayes'
theorem: when the prevalence of a disease in a
population is quite low. then a positive screen-
ing test result for that disease is likely to be
false-positive rather than true-positive. Yet be-
cause it is difficult to say with certainty that the
test is false-positive, the patient is likely to be
subjected to a prolonged, expensive course of
ceftriaxone.8 On the other hand, even a nega-
tive test result may not offer the patient suffi-
cient reassurance. Cases have been described
in which antibodies never developed despite
specific T-cell blastogenic responses to Bor-
relia burgdorferi (the causative spirochete).9
How can we say that a patient does not have
Lyme disease?

Although we can anticipate the development
of still-better tests for both diseases, the ulti-
mate solution to these “doctors' dilemmas"
would be eradication of the pesty-organisms
and/or their tick vectors. Filariasis. like ma-
laria and yellow fever before it, was eradicated
by focusing on the mosquito vector. Can we do
the same with the ubiquitous tick?

The tick. Its mouthparts. as disclosed by the
scanning electron microscope, form an awe-
some weapon worthy of any terrorist, replete
with barbs ideally designed for attachment to a
mammalian passer-by. It is fortunate that only
a few of the 850-odd species of ticks transmit
disease to humans, and that most attachments
even among these species are inconsequential.
It is unfortunate, however, that the Ixodes ticks
which transmit Lyme disease are small and
difficult to recognize on one's person. The key
vector is not the adult tick but rather the
nymph, which is almost imperceptible until
engorged by its blood meal. By then, it's too
late. In the New England states, some persons
now hesitate to venture into their own back-
yards for fear of these unseen enemies. Might
the same soon hold for South Carolina?

For now, it seems safest to assume that the
data presented by Schuman and Caldwell pro-
vide an accurate or even under-stated portrait
of tick borne diseases in South Carolina. We
should work to improve our familiarity with
these diseases, while advising patients who ask
what constitutes proper clothing for walking
through the woods.10 We should encourage the
kind of “teamwork among clinicians, ento-
mologists. and veterinarians" recommended
by these authors. Many more studies are
needed, but at least we have accomplished that
crucial first step: acknowledging that we do
have a problem. The investigators at MUSC’s
Agromedicine Program deserve our gratitude
for undertaking their important study.

— CSB

REFERENCES

1. Newsweek, May 22, 1989.

2. One prospective study indicated that 86% of patients
with Lyme disease had erythema marginatum. How-
ever. a study of a group of children presenting with
arthritis indicated that only 48% gave a history of this
lesion.

3. Durack DT : Rus in urbe: Spotted fever comes to town.
New Engl J Med 318: 1388-1390, 1988.

4. Helmick CG. Bernard KW, D'Angelo LJ: Rocky
Mountain spotted fever. Clinical, laboratory, and epi-
demiological features of 262 cases. J Infect Dis 1 50:
480-484, 1984.

5. Duff. J: Lvme disease. Infect Dis Clin North Am 3:
511-527, 1987.

6. Sigal LH: Lyme disease. 1988: immunologic man-
ifestations and possible immunopathogenetic mecha-
nisms. Sem Arth Rheum 18: 151-167, 1989.

7. Dattwyler RJ. Halperin JJ. Volkman DJ. et at Treat-
ment of late Lyme borreliosis — randomized com-
parison of ceftriaxone and penicillin. Lancet 1:
1191-1194, 1988.

8. Barbour AG: The diagnosis of Lyme disease: rewards
and perils (editorial). .Ann Intern Med 110: 480-484.
1984.

9. Dattwyler RJ. Volkman DJ. Luft BJ, et at Sero-
negative Lyme disease. Dissociation of specific T- and
B-hmphocMe responses to Borrelia burgdorferi. New
Engl J Med 319: 1441-1446. 1988.

10. Shorts are to be avoided: light-colored pants made of
tightly woven material and tucked into one's socks are
recommended. It should be remembered also that
tick-bearing animals prefer the same paths through the
woods that we do.

July 1989

343

ON THE COVER:

DAVIS FURMAN, M.D., 1858-1931
PRESIDENT, SCMA, 1905-06

In 1905, a year after its reorganization, the
SCMA met in Greenville, S.C., and Dr. Davis
Furman of that city was elected President. Dr.
Furman had received his medical degree from
the University of Maryland and practiced in
several different locations before coming to
Greenville. Here he was a popular physician
with a large practice. “He was not only the
ideal family doctor, but he was the perfect
family friend. He may have been called in as a
physician, but before he left, somehow you had
the feeling that you were richer by another
friend.”

Dr. Furman’s interests ranged beyond his
private practice. He was active in public health
in its early years, serving as Chairman of the
Greenville City Board of Health from 1911 to
1925 and taking an active role in establishing
the County Board. He later served on the State
Board of Health. His leadership was instru-
mental in securing a safe and adequate water
supply for his city, and he was a widely recog-
nized authority on the diagnosis and treatment
of pellagra.

During his term as President, the SCMA
established and published the first issue of this
Journal. Dr. Furman’s contribution to the is-
sue was “Cerebral Spinal Meningitis and
Hydrophobia.”

At his death, The Journal wrote: “He served
the state medical association and organized
medicine in general with marked enthusiasm,
and consistent loyalty. It was an inspiration to
the younger members of the profession to note
the presence of Dr. Furman wherever there
was a get together of medical men in his
vicinity although he was well beyond three
score years and ten. Dr. Furman was a pro-
found student of medicine, contributing im-
portant articles to the literature throughout his
long career. His contributions to public health
and his official connections with many health
organizations were notable. He was a valued
member of the State Board of Health of South
Carolina at the time of his death. He will be
sorely missed by a multitude of doctors and
other friends.”

AIDS

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344

Betty Newsom

The Waring Historical Library

The Journal of the South Carolina Medical Association

LETTER TO THE EDITOR

To The Editor:

Being a retired Chairman of Community
Health at Marquette University' and being a
retired Senior Citizen for the last three years, I
became more personally involved with the
older generation, non-ambulatory, and home-
bound patients in nursing homes and homes
where the elderly live.

I strongly feel there is a definite need to try to
reach this segment of the population and try to
uplift their dental health status. I am asking
your opinion for the need and use of involving
the physicians in their role in geriodontics. I
suggest having a Guest Editorial for your edi-
torial page in the Journal of South Carolina
Medical Association.

I am enclosing an adroit and thoughtful edi-
torial on The Role of The Physicians in Gerio-
dontics, at least. I feel it is. I seriously believe
this essay can be a starting point; in that it can
make the physicians cognizant and can be a
starting point in trying to uplift the dental
health status of this segment of the population
and help lessen the serious problem they have
now. The Dental Association is trying to help
this segment of the population, but I always
found the physicians appear to carry more
weight and respect and when they speak the
patients are more apt to listen and follow then-
suggestions.

THE PHYSICIAN’S ROLE
IN GERIODONTICS

Retirement in health, honor, and dignity are
the main circumstances that a person who has
reached his “golden years” wants to enjoy. The
majority of these persons have devoted five-
plus decades of their lives to performing, to the
best of their ability', some task that in some way
affects all of our fives, directly or indirectly,
and made this a better world in which to five.
As members of the health profession, w'hat do
we owe these people?

The number of elderly people in our popula-
tion is growing rapidly, and the physicians and
dentists are noticing that many of them have a
better understanding of total health, including
oral health, than their predecessors. A possible

reason is that in their younger days their teach-
ers, their physicians, their dentists, and the
media of communication taught them how to
preserve their teeth. Before long we may have a
generation of older individuals who drank
fluoridated water in their formative years, and
they may have teeth with lifetime quality.
With proper care and education, our older pa-
tients should not be candidates for complete
dentures. However, their teeth, oral soft tis-
sues, jawbones, the muscles and skin of the
face, all undergo aging changes closely related
to those which affect the rest of the body and
the mind.

Next to the dentists and dental hygienists,
the physicians are asked more questions on
oral health than anyone else by these geriodon-
tic patients, who are “special patients” only
because they find it hard or impossible to get to
see a dentist. Unless the physician learns to
evaluate the elderly person who brings his oral
problem along with his other problems, his
reputation as the physician of total health care
may be seriously challenged. It is not suggested
that the physician render dental services to
these elderly patients, but it is the physician’s
professional responsibility to see to it that he is
referred to a dentist, or get a dentist to come to
his patient. If one of the physician’s patients
has a medical disease for which he needs con-
sultation he does not hesitate to call in a medi-
cal specialist to examine his patient. Is it not
the professional responsibility of the physi-
cian, who is the key member of the health
team, to call in a dentist or refer his patient to
one. especially the nonambulatory or home-
bound patient?

The most prevalent diseases known to man
are oral diseases. .Almost every person has had.
has, or will have dental problems. Yet oral
problems are usually not contagious or deadly.
The undramatic nature of oral diseases un-
doubtedly contributes to the astonishing pro-
clivity of the physician to overlook these
conditions. The nondental public was condi-
tioned to believe that edentulousness was an
unavoidable concomitant of advanced years.
Many people were convinced that dentistry for
the elderly was limited to “grinding down their
false teeth.” But older individuals are no
longer willing to sacrifice their teeth. Dentistry
is more than plugging holes in teeth, bridging

July 1989

347

vacant spaces between teeth, or putting
“plates” in empty mouths. By restoring and
maintaining the oral cavity to the best condi-
tion for each person, we give these elderly
patients a feeling that “someone cares,” im-
prove their health and their esthetics and give
them a better outlook on life.

The mouth is regarded as an integral part of
the body entity because many oral diseases or
disorders are known to be correlated with a
systemic morbidity. The condition in the
mouth may be the cause or the effect of an
abnormality in the health of the body or of the
mind. The mouth is truly the “mirror of the
body” in that many symptoms or diagnostic
signs are first observed in the oral cavity. It is
the most accessible and acceptable orifice that
a physician can look into, and see further in-

side, without instruments. An oral cancer ex-
amination is within the realm of the physician.

The physician may not know of a dentist to
whom he can refer his patient. Dentists’ names
can be obtained the local dental society, the
local health department, or the nearest dental
school. The state dental society usually has a
list of dentists throughout the state who spe-
cialize in geriodontic patients.

The greatest sin of maturity is losing one’s
zest for life. Are the physicians contributing to
this loss by not treating the total health of their
patients even if it is only by referring them to
the proper discipline?

Fred R. Salerno, D.M.D., B.S., M.P.H.

1 14 Commons Way

Goose Creek, S. C. 29445

This space contributed as a public service.

348

The Journal of the South Carolina Medical Association

' OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

VOLUME 85

AUGUST 1989

NUMBER 8

REGIONALIZED PERINATAL CARE
IN SOUTH CAROLINA*

THOMAS C. HULSEY, MSPH, Sc.D.**

HENRY C. HEINS, M.D.

TERRY A. MARSHALL, M.D.

MARY LOU MARTIN, MSN, R.N.

TOM W. McGEE, M.A.T.

MARIE C. MEGLEN, MS, C.N.M.

SUSIE F. PEDEN, BSN, M.H.S.A.

WILLIAM B. PITTARD, M.D.

DAVID H. WELLS, M.D.

CONTENTS Page

I. HISTORICAL DEVELOPMENT 358

II. SYSTEMS DEVELOPMENT 363

III. THE ASSOCIATION OF HOSPITAL LEVEL OF CARE WITH MORTALITY

AMONG INFANTS OF VERY LOW BIRTH WEIGHT 375

IV. A REVIEW OF THE ISSUES 379

* From the Medical University of South Carolina, Charleston (Drs. Hulsey, Heins, and Pittard); Self Memorial Hospital,
Greenwood (Dr. Marshall and Ms. Peden); McLeod Regional Medical Center, Florence (Ms. Martin); The Office of
Primary Care, South Carolina Department of Health and Environmental Control, Columbia (Mr. McGee); The Office of
Maternal and Child Health, South Carolina Department of Health and Environmental Control, Columbia (Ms. Meglen);
Greenville Hospital System, Greenville (Ms. Peden and Dr. Wells); and Spartanburg Regional Medical Center, Spartan-
burg (Ms. Peden).

** Address correspondence to Dr. Hulsey at the Children’s Hospital, Department of Pediatrics, Medical University7 of South
Carolina, 171 Ashley Avenue, Charleston, S. C. 29425-3313.

August 1989

357

I. THE DEVELOPMENT OF REGIONALIZED
PERINATAL CARE.

The development of regionalized perinatal
care can best be traced from early national
efforts in the mid- 1920s, when health care pro-
fessionals sharpened their focus on the spe-
cialized needs of the preterm infant and began
to develop a distinct approach to care.1’ 2’ 3 The
refinement and acceptance of this health care
approach was fostered by the work of such
notable pediatricians as Dr. Julius Hess of Chi-
cago. Specialized centers for the care of the
premature neonate began to appear. The con-
cept in Chicago gained increasing support from
the medical community, and over the next 25
years developed into a program of care based
on physiologic principles including thermal
stability, nutrition, and specialized nursing
support.

During the 1960s the use of intensive care
for premature newborns continued to gain sup-
port. Many hospitals (primarily university
affiliated teaching institutions) established in-
tensive care programs with aggressive medical
care of high risk newborns. The growth of these
facilities was largely unregulated and fre-
quently resulted in an inefficient distribution
of resources. With few exceptions, the early
increase of newborn intensive care units was
not carefully planned. Personnel were fre-
quently inadequately trained. Knowledge was
deficient at some hospitals and technological
applications were inconsistent in others. In
some areas there was a lack of intensive care
while in others there were costly duplications.

Several professional groups, concerned
about the rapid growth of neonatal intensive
care units (NICU), began to issue policy state-
ments that supported the concept of care based
on patient risk and included the aspect of effi-
cient use of community resources. Most nota-
bly were the efforts of the American Academy
of Pediatrics, the American College of Obste-
tricians and Gynecologists, and the American
Medical Association.

In 1971, the American Medical Association
issued the statement: “Application of recent
advances in scientific knowledge and skills in
the intensive care management of high risk
pregnant women and high risk newborn in-
fants will result in reduction of present mater-

nal and infant mortality. A major contribution
to such a program is the development of a
centralized community hospital-based new-
born intensive care unit. Concentration of high
risk infant care programs in a hospital specifi-
cally staffed and equipped to provide optimal
care is a proven life-saving mechanism for
infants at risk.”4

In the sixth edition of the Standards and
Recommendations for Hospital Care of New-
born Infants, the American Academy of Pedi-
atrics, concerned about the lack of standardiza-
tion of care, gave detailed recommendations
for the level of services an institution provided
and emphasized the need to make the most
skilled, intensive care available to the mothers
and infants at highest risk.5

Nevertheless, a rather haphazard growth of
NICUs continued, and in 1976, represen-
tatives of the American Academy of Pediatrics
and the American College of Obstetricians and
Gynecologists were drawn together on a March
of Dimes Committee for Perinatal Health to
establish guidelines for the future growth and
use of NICU facilities. The resulting publica-
tion, Toward Improving the Outcome of Preg-
nancy, defined resources essential for the
provision of specific support services. It is this
document that first described the concept of
regionalized perinatal care. “Regionalization
implies the development, within a geographic
area, of a coordinated, cooperative system of
maternal and perinatal health care in which, by
mutual agreement between hospitals and phy-
sicians and based upon population needs, the
degree of complexity of maternal and perinatal
health care each hospital is capable of provid-
ing is identified so as to accomplish the follow-
ing objectives: (1) quality care to all pregnant
women and newborns, (2) maximal utilization
of highly trained perinatal personnel and in-
tensive care facilities, and (3) assurances of
reasonable cost effectiveness.”4

The ACOG Committee on Obstetrics: Ma-
ternal and Fetal Medicine and the AAP Com-
mittee on Fetus and Newborn published the
Guidelines for Perinatal Care in 1983, which
identified hospital level designation, physical
facilities, staffing needs, and introduced the

358

The Journal of the South Carolina Medical Association

REGIONALIZED PERINATAL CARE

concept of systems development. These guide-
lines provide the following framework for re-
gional programs. “Regional delivery of peri-
natal health care is a systems approach in
which program components in a geographic
area are defined and coordinated. Successful
systems meet local needs and support indi-
vidual physician-patient relationships. They
emphasize communication and education,
consultation and professional competence in
the utilization of services according to patient
needs, and cost-effective services, including
consolidation when indicated.”6

The important concept is that regional peri-
natal care is a complex coordination of many
independent programs and certainly much
more than the existence of an array of intensive
care nurseries. Service, education, patient
transport, follow-up, and research are required
components and must be balanced to facilitate
a continuation of improvement in care
through expansion of knowledge and skills,
proper allocation of resources, and advance-
ment and dissemination of prevention and
treatment methodologies. Involvement of
obstetrical and neonatal services, as well as
local physicians and public health departments
into a system of united care is a requirement
for success.

The long term goals of a regional system
include ( 1) the reduction of maternal, fetal, and
neonatal mortality and morbidity to the lowest
attainable levels, and (2) efficient utilization of
available resources, balanced with patient
needs.

For South Carolina, it was perhaps the 1972
survey of hospitals with maternity services
which provided the initial groundwork for re-
gionalization. Funded by the March of Dimes,
this survey examined the relationship between
number of hospital deliveries and perinatal
mortality, efficiency of resource use, and qual-
ity of service delivery. Its purpose was “to
promote emergence of statewide standards of
practice of perinatal care and improve utiliza-
tion of resources.”7

The first formal efforts at structuring region-
alized perinatal care in South Carolina began
around 1973. At that time, a group of health
care professionals developed guidelines based
on the results of the 1972 survey. These guide-
lines served as a beginning for the develop-

ment of a standard approach to resources and
care. In 1974, a state document, South Caro-
lina Regionalization of Perinatal Health Care,
outlined the broad goals and cooperative
agreements required for a successful imple-
mentation.7 This original concept was also in-
troduced in The Journal of The South Carolina
Medical Association .8 These directives in-
cluded: (1) the regionalization concept, delin-
eating various levels of care; (2) a plan for early
identification of high risk pregnancies; (3) a
statement of need for a well-developed trans-
portation system for mothers and infants; (4)
an emphasis on the need for better perinatal
education of professional personnel and the
public; (5) a call for better hospital staffing;
and, (6) a plea for financial support of perinatal
health care services on a statewide basis.

This initial plan designated three state peri-
natal regions and their respective perinatal
centers. The Medical University of South Car-
olina in Charleston was responsible for 16 pri-
marily coastal and buffer counties, Richland
Memorial Hospital in Columbia was responsi-
ble for 17 midlands counties, and the Green-
ville Hospital System in Greenville was re-
sponsible for 13 Piedmont and mountain
counties.

The Department of Health and Environ-
mental Control (DHEC), through the Maternal
and Child Health Bureau’s High Risk Perinatal
Program, implemented its first program for
regionalized care in selected areas of the state
in 1974.9 This pilot program provided finan-
cial support for prenatal care and delivery of
high risk patients, as well as support for nurses,
aides, social workers, nutritionists, and edu-
cators to assure delivery of comprehensive
health care services.

DHEC expanded this program statewide the
following year. These original efforts were pri-
marily directed toward two activities. The first
was payment for high risk services and the
second was the designation of levels for hospi-
tals (I, II, or III) based on capability and patient
risk status.

There were other significant contributors to
the initial development of perinatal health in
South Carolina. One of the principal groups
that helped establish regional perinatal care
was the March of Dimes. Their initial efforts
were often directed toward equipment pur-

August 1989

359

REGIONALIZED PERINATAL CARE

chases for new neonatal intensive care units
and assistance in staff education. The commit-
ment of the March of Dimes to perinatal health
and professional education continued with fur-
ther assistance in research, demonstration
projects, support of systems development, and
support of the South Carolina Perinatal Asso-
ciation.

In 1979, the original 1974 plan was revised
and updated. The South Carolina Perinatal
Association’s multidisciplinary Perinatal Ad-
visory Committee (PAC) subdivided into four
regional perinatal advisory committees (based
on the four existing health system agency
[HSA] designations) and each assessed the
perinatal health status of its region of the state.
This assessment identified specific problems
and potential solutions for improving the re-
spective region’s perinatal health status and
the provision for perinatal health care. As a
result, the Guidelines for Achieving Perinatal
Health in South Carolina were written based
on the new information and directives from
other health organizations (State Health Plan
and the National Discipline Standards of
ACOG, AAP, APHA, ACNM, NAACOG,
ANA, etc.).10 It was at this same time that
perinatal regionalization efforts were gaining
rapid support nationally, resulting in the first
printing of the document, Toward Improving
the Outcome of Pregnancy in 1976.

There were several notable changes from the
original 1974 plan. The state was divided into
four geographic regions based on the numbers
of births in each area. The MUSC perinatal
region was divided due to the development of
McLeod Regional Medical Center in Florence
and the need to recognize four HSA health
planning regions. MUSC would now be re-
sponsible for the seven southern coastal coun-
ties and McLeod would be responsible for the
nine northern coastal counties. The other two
perinatal regions were unchanged.

Other revisions included changes in finan-
cial support to include outpatient care from
conception through the neonate’s first year of
life; statement of minimum standards and nec-
essary capabilities for each type of hospital;
inclusion of guidelines regarding consumer is-
sues and special groups of consumers; and,
inclusion of guidelines for all of the disciplines
involved in perinatal care. Much more de-

tailed than the 1974 plan, the 1979 plan de-
scribed specific hospital requirements and
responsibilities for each perinatal level of care.

In July, 1983, South Carolina Governor
Richard Riley, by executive order, formed a
Governor’s Council on Perinatal Health. This
Council was charged with assessing the current
status of services affecting perinatal health,
identifying gaps in assuring perinatal health
care, and developing a plan identifying specific
steps for improvement. The council included
representatives from the S.C. Medical Associa-
tion, Hospital Association, Nurses Associa-
tion, Department of Education, Department of
Social Services, Department of Health and En-
vironmental Control, the Statewide Health
Coordinating Council, the Governor’s Council
on Rural Development, the State Community
Action Agency, the Primary Care Association,
the Palmetto Medical, Dental and Pharma-
ceutical Association, the South Carolina Peri-
natal Association, consumers, and at-large
members.

The assessment of the committee, the Peri-
natal Health Services Assessment, was pre-
sented to Governor Riley in December, 1983,
containing a needs assessment and recommen-
dations for remediative action.11 Following
this assessment, the Perinatal Plan of Action
was prepared describing the implementation
of the recommendations contained within the
assessment.12

Implementation of the action plan began in
April of 1984. The action plan covered a wide
variety of steps for improving perinatal health
and a timetable for their completion. The time-
table suggested that initiatives were to begin in
1984 with final completion in 1987. The Peri-
natal Plan of Action also contained specific
recommendations for reaching these goals
through corrective action and new initiatives.
The recommended actions were based upon
currently available or anticipated manpower
and financial resources, and involved various
public and private agencies and organizations
throughout the state.

In April, 1985, Governor Riley designated
the Bureau of Maternal and Child Health of the
Department of Health and Environmental
Control as the agency to oversee the imple-
mentation of the Perinatal Plan of Action. The
Bureau of Maternal and Child Health was to

360

The Journal of the South Carolina Medical Association

REGIONALIZED PERINATAL CARE

provide to the Governor and selected agency
heads an annual status report on the imple-
mentation of the specific guidelines.

Today, almost all of the recommendations
from the Action Plan have been accomplished.
These include extending and funding Med-
icaid coverage to the medically needy, receiv-
ing a waiver from the Health Care Financing
Administration to “channel” pregnant women
determined to be at high risk to appropriate
care providers and delivery settings (High Risk
Channelling — HRCP), and maintaining the
low birth weight prevention program. In addi-
tion, a statewide Healthy Mothers, Healthy
Babies coalition has been established to pub-
licize problems associated with perinatal
health. A final report was completed in 1 988. A
subsequent executive order by Governor Riley
in 1986 established the Governor’s Council on
Maternal, Infant, and Child Health. This is a
permanent committee which reports annually
to the Governor and the legislature on the
progress and plans for improving maternal and
infant health in South Carolina. This activity
insures the continuity of past efforts across
various administrations of the Governor’s
Office.

South Carolina elected to participate in the
expansion of the Medicaid coverage for preg-
nant women and infants and began this cover-
age on October 1, 1987. This coverage in-
creased the income eligibility for pregnant
women from 50% of poverty (under the old
guidelines) to 100% of poverty. A major
milestone, this action not only ensured finan-
cial access to care for many poor women and
children, but finally uncoupled Medicaid pay-
ments from Aid to Families with Dependent
Children (AFDC) grants administered by the
Department of Social Services. It is anticipated
that Medicaid coverage with expanded bene-
fits will increase to 1 50% of poverty by the end
of FY89.

The Bureau of Maternal and Child Health
revised and updated the 1979 approach to re-
gional perinatal care in October, 1986. The
most significant changes targeted inpatient
payments for newborn care. These funds,
which had previously been used to pay for
indigent newborn care, were redirected to sys-
tems development of regional perinatal care.
Contracts with each of the six regional centers

(comprising the four perinatal regions) stipu-
late the following requirements: (1) Each re-
gion must employ a coordinator (Regional
Systems Developer) to oversee the contract
requirements within the respective regions, act
as a liaison between the center and community
hospitals, and perform an annual regional
needs assessment; (2) Transport programs:
each perinatal region is required to have a
functional neonatal transport program and, in
addition, is to pursue the development and
operation of a functional maternal transport
program; (3) Educational outreach: each peri-
natal region is to provide continuing education
to hospitals, community health clinics, and
public health agencies within the region; (4)
High risk developmental follow-up: each per-
inatal region must identify certain graduates of
the neonatal intensive care unit in the respec-
tive centers and assure the provision of follow-
up for health assessments for these at-risk in-
fants; (5) Data collection: each regional center
is to collect information on graduates of the
neonatal intensive care unit as well as the ac-
tivities of the above outlined functions for sub-
mission to the Bureau of Maternal and Child
Health.

These efforts continue throughout the state.
Evaluation of regionalization has been per-
formed through DHEC’s Five Year Plan peri-
natal impact objectives. The Bureau of Mater-
nal and Child Health is also developing a sur-
veillance system with the aid of a Centers for
Disease Control assignee, Dr. Bill Sappenfield,
to monitor South Carolina’s regionalization
system.

The current form of perinatal regionaliza-
tion takes those recommended by the Guide-
lines for Perinatal Care and expands them for
greater efficiency. This strategy has been uti-
lized in several other states with exceptional
success.13’ 14 The present approach to region-
alized perinatal care has proven cost effective
in both resources and services. Not only has
systems development lowered fetal and neo-
natal mortality, the gains were puchased at a
savings to the public.15’ 16

For South Carolina to fully reap the benefits
of over 15 years of dedicated attention from
health care professionals, we must continue to
support our regionalized perinatal care efforts.
Professionals and public alike must realize that

August 1989

361

- REGIONALIZED PERINATAL CARE -

regionalization does not mean having an in-
tensive care nursery in every community. We
must guarantee that assuring patient care
based on health risk in an efficient cost-effec-
tive manner, insisting on a strong facilities
review process, and relying on specific health
care needs as the sole motivation in expendi-
tures and further regional development are key
elements in our regionalization efforts. The
end result will be better perinatal health care
for all South Carolinians. □

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STATI0N-T0-STATI0N COLLECT

II. SYSTEMS DEVELOPMENT: SOUTH CAROLINA’S
APPROACH TO REGIONAL PERINATAL CARE.

Formal plans for the regionalization of per-
inatal care services differ among the states. The
structure of these range from simple designa-
tion of hospital level of care to very detailed
contracts which outline the responsibilities of
each health care participant. This article is
designed to familiarize physicians and others
with the specific approach toward perinatal
regionalization in South Carolina.

DEVELOPMENT

As noted in the previous chapter, the origi-
nal activities targeting regional perinatal care
were primarily directed toward payment for
high risk maternal and infant services and
identification of hospital capability to care for
patients with varying degrees of risk. In Oc-
tober, 1986, the strategy to regionalize care in
the state was restructured from one primarily
of reimbursement for patient care to one of
systems development.

Systems development is a process which
first identifies the various programs and pro-
viders involved in the care of the mother and
infant throughout the childbearing cycle and
secondly, attempts to assure the coordination
of these independent programs to achieve a
cost effective comprehensive plan of care for
patients. Simply, systems development at-
tempts to assure the coordination of existing
programs into a unified approach toward a
common goal. For perinatal care, the systems
approach attempts to enhance the coordina-
tion of obstetrical and neonatal support
through cooperative agreements with health
departments, community health centers, pri-
vate physicians, community hospitals, re-
gional hospitals and other perinatal health care
providers.

These cooperative agreements target indi-
vidual program components with particular
emphasis on early determination of patient
risk, access to risk appropriate care and case
management. Full development of regional
systems of perinatal care should ensure appro-
priateness of care (care which is appropriate to
the risk status of mother and infant) and con-
tinuity of care (care that continues from con-
ception through the first year of life.).

A successful program would determine the
health risk and needs of specific populations
within a defined area and identify factors
which might impede the delivery of risk ap-
propriate care. Operationally, these areas are
addressed by the Regionalized Perinatal Care
program administered by DHEC-BMCH-
DMH (South Carolina Department of Health
and Environmental Control — Bureau of Ma-
ternal and Child Health — Division of Mater-
nal Health) through contractual arrangements
in each of the four perinatal care regions in
South Carolina.

CONTRACTS

In each region there is a hospital or group of
hospitals responsible for the perinatal systems
development in their respective geographic
areas (see Figure I). As noted, there are four
regions designated. In Region I, there are three
hospitals which function as a consortium for
the regional perinatal program (Self Memorial
Hospital, Spartanburg Regional Medical Cen-
ter, and Greenville Hospital System).

There is a single regional center in the other
three regions. These are Richland Memorial
for Region II, McLeod Regional Medical Cen-
ter for Region III, and the Medical University
of South Carolina for Region IV. Each of the
six regional centers have completed contracts
with DHEC which outline their role and re-
sponsibilities as regional centers. Each con-
tract contains the following component pieces.

(1) Regional Systems Developer (RSD)

The regional systems developer is an indi-
vidual employed jointly by the regional center
and DHEC to oversee the requirements of the
contract and coordinate the systems develop-
ment activities. Perhaps the most significant
RSD role is the development of an annual
needs assessment which identifies problem
areas (both programmatic and geographic)
which restrict the delivery of risk appropriate
care and continuity of care. This assessment is
designed to target strengths and weaknesses in
the delivery of risk appropriate care to the
mother (both antepartum and intrapartum)
and the neonate. Data from both the public

August 1989

363

REGIONALIZED PERINATAL CARE

and private sectors are examined and include
such areas as availability of prenatal care,
transportation access for both mother and
newborn, distribution of births by birth weight
(geographically and by hospital), and various
outcome statistics.

The RSD also serves as a liaison between the
community and the regional center with a par-
ticular emphasis on the reduction of barriers to
risk appropriate care, barriers to continuity of
care, and the promotion of case management
of the high risk patient. The RSD serves to
identify obstacles to regionalization and its ef-
fectiveness and to initiate steps to eliminate
them. Questions regarding the specific opera-
tion and administration of any of the regional
perinatal health care programs may be directed
to the regional systems developer (RSD) for
that region (see Table 1).

(2) Educational Outreach

An essential element of regionalized care is
the ongoing dissemination of information
from the regional center to the health care
providers in their contract region. A major

component is the professional obstetrical and
neonatal education offered by most regional
centers to the various health care providers in
the region. Each region is able, through either
the obstetrical educator or the newborn edu-
cator, to tailor programs to the community
needs. The outreach educators present an on-
going series of seminars specific to the educa-
tional needs identified in the region’s com-
munity hospitals and health departments
which focus on specific topics such as identifi-
cation of the high risk pregnancy, newborn risk
assessment, resuscitation and stabilization for
transport and management of the growing pre-
mature infant. Health care providers may (and
frequently do) request specific topics of special
interest to them. Hospital physicians, nurses
and others are also invited, in some regions, to
participate in the Charlottesville Perinatal
Continuing Education Program (PCEP) which
is a self-paced formal course for the commu-
nity physicians and nurses. An important seg-
ment of the outreach education program
involves case presentations in the community
hospital of patients referred from that hospital

364

The Journal of the South Carolina Medical Association

REGIONALIZED PERINATAL CARE

TABLE 1.

County

Regional Center

Outreach

Transport

RSD

Aiken

Allendale

Bamberg

Barnwell

Calhoun

Chester

Clarendon

Fairfield

Kershaw

Lancaster

Lee

Lexington

Newberry

Orangeburg

Richland

Sumter

York

Richland Memorial
Hospital

Fran

Byrd

765-6392

Fran

Byrd

765-6392

Lisa

Hobbs

253-4302

Beaufort

Berkeley

Charleston

Colleton

Dorchester

Hampton

Jasper

Medical University
of South Carolina

Kathy Ray /
Eliz. Jones
792-2112

Pat

Wagstaff

792-9544

Tom

Hulsey

792-5179

Chesterfield

Darlington

Dillon

Florence

Georgetown

Horry

Marion

Marlboro

Williamsburg

McLeod Regional
Medical Center

Pam Brown /
Jeannie
Thompson
667-2455

Jeannie

Elmore

667-2483

Marylou

Martin

667-2483

Anderson

Greenville

Oconee

Pickens

Greenville Memorial
Medical Center

Bridget

Allen

242-7939/

Betty

Humphries

242-8205

Carole

Whitten

242-7165

Abbeville

Edgefield

Greenwood

Laurens

McCormick

Saluda

Self Memorial
Hospital

Rebecca

Grup inski

227-4449/

Betty

Humphries

242-8205

Ron

Deeder

227-4494

Susie

Peden

242-8205

Cherokee

Spartanburg

Union

Spartanburg Regional
Medical Center

Kathy

McCoy

591-6380/

Betty

Humphries

242-8205

Treasure

Snyder

591-6297

DHEC Central Office
Coordinators assigned to
monitor Regional
Perinatal Program
components .

Data Collection

Developmental Follow Up Clinics

Marie Thompson
737-4050

Outreach Education (OB and Neo)
Maternal and Neonatal Transport
Regional Systems Developers

Tom McGee
737-3995

August 1989

365

REGIONALIZED PERINATAL CARE

as well as inservice training for community
hospital nurses in the regional center. In addi-
tion, it is anticipated that an obstetrical con-
tinuing education module, developed by Dr.
Henry Heins and Jean E. Martin RN, CNM,
MS, MSN, will soon be available.

Each region is required to present either an
annual perinatal seminar or an obstetrical and
neonatal seminar to facilitate communication
between the community providers of perinatal
care and the regional center staff. Information
regarding outreach education and requests for
inservice/presentations may be requested
from the outreach educator in each center.

(3) Emergency Transport

Critical to the success of regionalized per-
inatal care is a system by which patients are
transported to facilities for risk appropriate
care. Each regional center has the responsibil-
ity to assure that high risk obstetric and new-
born patients have access to emergency trans-
port as needed. Community hospitals within a
region may assume that their respective desig-
nated regional center has an emergency trans-
port plan for its region. As such, the commu-
nity hospital should call its designated regional
center whenever a transport is indicated. That
center will assure the appropriate transport. All
regional centers have access to ground trans-
port locally, and any regional center may
request air transport by coordinating with the
appropriate neonatologist for MAST dis-
patched by Richland Memorial or MEDU-
CARE dispatched by the Medical University.

Inter-regional transports occur through re-
quests from one regional center to another
regional center. To assure the shortest response
time, therefore, community hospitals should
contact their respective regional center for
transport assistance.

As with the educational outreach and RSD
components, each regional center has an indi-
vidual (or individuals) who serves as the neo-
natal transport coordinator or the maternal
transport coordinator. Any questions regard-
ing transport policy or transport procedures
may be directed to the transport coordinator in
the appropriate center.

(4) Developmental Follow Up

Although criteria for entry into the various

follow up programs vary according to region,

each center is charged with assuring that chil-
dren at risk for developmental disability are
followed by a team of specialists. The follow-
up team differs in each center, but usually
consists of a physician, social worker, nurse,
physical/occupational therapist, child psychol-
ogist, or developmental specialist.

Assessments are provided at no charge to the
patient and children may be enrolled at some
centers for up to seven years post-discharge
(depending on the specific region). None of the
developmental follow-up programs are identi-
cal as each utilizes the particular resources
available in its regional center. Most are de-
signed as screening programs, however, and do
not provide primary care. Children with sus-
pected or identified health problems are re-
ferred to the appropriate health provider for
assessment and treatment as needed. The high
risk developmental follow-up teams coordi-
nate their services with those of the private
physician and/or public health community as
appropriate.

Each regional center participates in a state-
wide developmental information system cen-
tered in DHEC. This system is designed to
determine those child populations which are
particularly vulnerable to developmental de-
lay in the early years of life. Over time, the
DHEC system should be able to identify those
risk categories which, through early identifica-
tion and case management, should receive spe-
cialized intervention designed to maximize
quality of life.

(5) Data Collection

Each center is required to report to DHEC
certain information regarding admissions to
and discharges from their newborn intensive
care programs. Information on systems devel-
opment, educational outreach, transports, and
developmental follow up are also required. As
these data are accumulated, DHEC will be able
to identify the strengths and weaknesses of the
various activities contained within the state’s
regionalized perinatal care efforts.

The South Carolina regionalized perinatal
care program is designed after the framework
outlined in Guidelines for Perinatal Care.4 * 6
There are obvious slight modifications but the
original intent of risk appropriate care com-
bined with efficient utilization of resources re-

366

The Journal of the South Carolina Medical Association

REGIONALIZED PERINATAL CARE

mains. Communication and coordination
between health departments, physicians, hos-
pitals, community health centers, as well as
nurses, obstetricians, neonatologists, pediatri-
cians and others is necessary if we are to reduce
our high perinatal mortality rates. A long term
commitment of perinatal health care providers
toward systems development can ensure its
eventual success. □

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NEWSLETTER

HIGHLIGHTS OF JULY BOARD OF TRUSTEES MEETING

The primary goal of SCMA President Daniel W. Brake, MD, is to
identify the direction in which health care should move into the
next century. The newly-formed SCMA Health Care 2000 Committee
composed of a cross-section of the population, including patients
and providers, will address this issue by conducting an in-depth
study of the health care system as it exists today. The
committee plans to direct its efforts toward impacting health
care at the state level, and perhaps even at the national level.
Topics for discussion at future committee meetings include the
Medicare program and the ethical issues involved in the most
appropriate use of health care resources.

MEDICARE UPDATE

Physician Identification Numbers

By now you should have received a July 6 Medicare Advisory
stating that HCFA has postponed the requirement that a referring
physician ID number be included on claims of radiologists,
pathologists and physicians using a consultation code. It
appears that sometime this fall, HCFA will issue a UPIN (unique
provider identification number) to all physicians, and this
requirement will again be in effect.

Expenditure Targets

You should also have received a letter from the AMA alerting you
about "ETs" (expenditure targets) . As explained in Dr. John
Hawk's AMA update in last month's Journal, the AMA is strongly
opposing this proposal which would attempt to balance the federal
budget by limiting future Medicare expenditures, no matter how
medically necessary the care might be, if annual Medicare costs
exceed the projected target. Write to your congressmen and
senators asking them to vigorously oppose "ETs” in the Medicare
program or any other action which would lead to the rationing of
or reduction of access to medical care.

MEDICAID UPDATE

FY ' 90 Appropriations Act

The SC General Assembly increased the state budget by 11 percent
with a $3.5 billion FY'90 Appropriations Act. Along with
substantial outlays for education and prisons, the record
spending bill provides a big increase for health and human
services, including $592 million for the Medicaid program, a 48

percent increase over this year's budget.

The $15 million Medically Indigent Assistance Fund will be folded
into the state contribution and used to attract additional
federal matching funds effective July 1.

Income Eligibility Increase for Pregnant Women & Infants

As reported in the July "SCMA Newsletter", the Medicaid Program
has increased the income eligibility limit for pregnant women and
infants to 185 percent of poverty, or $18,600 per year for a
family of three. It is important to note that a "family of
three" would include a father and an expectant mother. This 185
percent level is in effect for children up to the age of one
year. It is hoped that this new funding for prenatal and
postnatal care will significantly cut the state's high infant
mortality rate by reducing the number of infant deaths and
physical and mental impairments caused by inadequate medical care
for expectant mothers and infants.

Increase in Prescription Drug Limit

Effective July 1, 1989, the Medicaid Program will pay for a
maximum of four prescription drugs per month per recipient rather
than three. Insulin syringes and specially authorized home
parenteral therapies are still excluded from the new monthly
limit. The $1 co-payment per prescription drug for non-exempt
recipients is still in effect.

Change in Reimbursement for Physical Examinations

Physical examinations for adults age 21 and older will be
reimbursed by Medicaid at a rate of $100 per examination
effective July 1. These examinations are limited to one
examination per recipient every five years. Providers must
submit claims for this physical examination using procedure code
90750 and diagnosis code V70.9.

PRO UPDATE

"20-Day" or "30-Dav" Letters

Initial physician review in the peer review process often leads
to the generation of "20-day" or 30-day" letters. These letters
are strictly requests for additional or clarifying information;
they are not denials or sanction letters. The information
provided by the attending physician is added to the medical
record before the record is sent for a second review. Failure to
respond to the letters results in a decision being made without
additional input.

Carolina Medical Review encourages all physicians to take
advantage of the opportunity to provide more information.
Additionally, a telephone conference with a physician consultant

is also available if requested in writing in response to a "20-
day” or "30-day" letter. Most problems are cleared after this
additional information is received.

Quality Intervention Plan

Effective April 1, 1989, the nation's 54 PROs began implementing
the new provisions in HCFA's Third PRO Scope of Work. The
Quality Intervention Plan (QIP) is a new provision which requires
PRO physicians to identify and confirm quality concerns in cases
they review. The QIP sets forth three levels of medical
mismanagement according to whether there are significant,
potential or no adverse effects on the patient. Each level is
assigned a severity weight.

Each quarter, the PRO will profile the total weights accumulated
for reviews completed during that quarter for each physician or
provider. The total severity weight will determine the type of
corrective action to be implemented. The PRO must initiate
corrective action when any provider receives a total weighted
score of three or more. Interventions and trigger levels are
notification (3) , educational efforts (10) , intensified review
(15) , other interventions (2) , consideration of coordination with
licensing and certification bodies (25) , and consideration of
sanction proceedings (25) . Each PRO is required to use the HCFA
QIP and implement the intervention inclusive of lesser trigger
levels. In other words, a score of 19 would require
notification, educational efforts and intensified review. The
PRO must exercise flexibility in determining what intervention is
appropriate to the particular case.

AIDS UPDATE

OSHA Proposed AIDS-Protection Rule

In the May 30 issue of the Federal Register, the Occupational
Safety and Health Administration proposed a rule designed to
protect health-care workers from exposure to bloodborne
pathogens, particularly the viruses which cause hepatitis and
AIDS.

The rule, "Occupational Exposure to Bloodborne Pathogens:
Proposed Rule and Notice of Hearing," will affect all health-care
workers who may come into contact with blood and other
potentially infectious materials. Copies may be obtained by
calling Kim Fox or Joy Drennen at SCMA Headquarters.

STATE SALES AND USE TAXES

Effective July 1, 1989, sales of dental prosthetic devices,
whether sold by prescription or not, are exempt from the sales
and use tax. However, sales of all other prosthetic devices and
medicines must still be sold by prescription in order to be
exempt .

LIMITS SET FOR PHOTOCOPYING RECORDS

Effective June 8, 1989, physicians may charge $5 or 50 cents per
page, whichever is greater, plus actual postage costs, for
photocopying patient records for Workers' Compensation claims.
This covers only existing information and does not include any
written summaries or opinions reguested. If the information is
not received from the physician within 45 days of receipt of
request, the physician may be fined up to $200.

Effective July 1, 1989, physicians may charge $10 or 50 cents per
page, whichever is greater, for furnishing copies of patient
records for automobile insurance claims.

PUBLICATIONS/VIDEOTAPES AVAILABLE

"Collective Negotiation and Antitrust," a publication of the new
Physician Negotiation Advisory Office within the AMA's Office of
the General Counsel, is now available. The booklet explains
antitrust laws, how they affect physicians' practice, and what
MDs and medical societies can do with respect to third-party
payers. AMA members can get a free copy by calling (312) 645-
5601.

A videotape of the SCMA/SCHA conference held in June on
"Eliminating Risks in the Emergency Room" is available at a cost
of $65.00. Contact Doris Clevenger, SCHA, PO Box 6009, West
Columbia, SC 29171 or call 1-796-3080.

MEMBERSHIP ACHIEVEMENT

Bamberg and Chester Counties have joined Hampton County Medical
Society in achieving 100 percent membership in the SCMA.

UPCOMING CONFERENCES

The 14th Annual Assembly of the AMA-Hospital Medical Staff
Section (AMA-HMSS) will be held November 30 - December 4, 1989 at
the Sheraton Waikiki Hotel, Honolulu, Hawaii. Medical staffs are
encouraged to elect a representative to participate in this
assembly which provides a unique opportunity to discuss and
participate in the policymaking process of the AMA. In addition
to the assembly meeting, the HMSS will sponsor an educational
program on a topic of interest to medical staffs. For further
information, call (312) 645-4754 or 4761.

The SC Area Health Education Consortium (SC AHEC) Center for
Recruitment, Retention and Placement will sponsor their 4th
Annual Practice Opportunities Fair on September 8-9 in Columbia.
The fair is designed to help residents identify and evaluate
practice opportunities throughout the state. For further
information, call Mary Chesshire or Becky Seignious at 1-792-
4431.

III. ASSOCIATION OF HOSPITAL LEVEL OF CARE WITH
MORTALITY AMONG INFANTS DELIVERED VERY LOW
BIRTHWEIGHT

For every 1,000 babies born in South Caro-
lina in 1986, 13 died during their first year of
life, making South Carolina’s infant mortality
rate among the highest in the nation. As in
most states, approximately two-thirds of these
deaths occurred during the first 28 days of life,
the neonatal period. Infants with birthweights
between 500 and 1 500 g (very low birthweight)
constituted over 40 percent of these neonatal
deaths while representing less than two percent
of the total births.

Efforts to lower the infant mortality rate
have targeted both the reduction of low weight
births and aggressive medical management of
high risk babies. Survival rates increase mark-
edly when very low birthweight (VLBW) in-
fants are born in regional perinatal centers.14

Investigators of neonatal mortality rates by
the level of medical care available in the hospi-
tal of delivery indicate significantly greater sur-
vival rates, particularly among the very low
birthweight groups, for infants delivered in
perinatal centers or tertiary hospitals.17'20 To
determine whether similar patterns in neo-
natal mortality exist in South Carolina, the
present study compared the VLBW neonatal
mortality rates in regional perinatal centers
with those of non-regional community hospitals.

METHODS

Vital statistics records of hospital births of
infants weighing 501-1499 g (VLBW) were ex-
amined for 1984-86. Neonatal mortality rates
for VLBW infants were computed for both
non-regional community hospitals and high
risk regional perinatal centers. Mortality rates
were computed as the number of deaths among
VLBW neonates in a hospital group divided by
the number of inborn live VLBW births in that
hospital group x 1000. Since this report
focused on hospital of delivery, neonatal mor-
tality rates were computed for hospital of birth.
If a non-regional community hospital trans-
ferred a neonate to a high risk regional center
for care and the child later died in the regional
center, the death was recorded for the commu-
nity hospital as the hospital of birth.

For the purposes of this report, the following
hospitals were operationally defined as high
risk regional perinatal centers: Greenville Me-
morial Medical Center, Spartanburg Regional
Medical Center, Self Memorial Hospital, Rich-
land Memorial Hospital, McLeod Regional
Medical Center, and the Medical University of
South Carolina. All other hospitals were classi-
fied as non-regional community hospitals.

It is acknowledged that there are tertiary
hospitals in South Carolina which are not re-
gional perinatal centers. Since it is impossible
to measure the qualitative care within hospi-
tals, or across levels of hospital designations,
this analysis relied on the regional center desig-
nation for comparisons. This classification
was more objective and no other implication is
made. This is an important distinction and
should not be misinterpreted.

RESULTS

Overall, from 1984 to 1986, South Carolina
experienced no significant change in either the
incidence of VLBW births or the neonatal
mortality among VLBW infants (see Table 2).
There appeared to be a shift, however, in the
location of both VLBW births and VLBW neo-
natal mortality. During this three-year period,
fewer VLBW births were delivered in commu-
nity hospitals (Figure II). The VLBW neonatal
mortality in community hospitals increased,
although the increase was not statistically sig-
nificant. From 1984 to 1985, community hos-
pitals contributed an increasing proportion of
deaths to the state’s total mortality. The contri-
bution from community hospitals from 1985
to 1986 was unchanged.

There were statistically significant differ-
ences in the VLBW neonatal mortality be-
tween community hospitals and regional peri-
natal centers (see Figure III). For 1984, the
VLBW neonatal mortality for regional per-
inatal centers was 26.2% compared to 35.5%
for community hospitals (X2:p<0.01).21 For
1985, the VLBW neonatal mortality for re-
gional perinatal centers was 24.5% compared to
44.4% for community hospitals (X2:p<0.01).22

August 1989

375

REGIONALIZED PERINATAL CARE

Distribution of Very Low Birthweight (VLBW: 500-1500 grains

birthweight) Births and Neonatal Deaths in South Carolina
Hospitals, 1984 - 1986.

1984 1985 1986

S.C. Total

Hospital

Births

48197

49397

49468

S.C. Total

VLBW

Births

725

730

687

S.C. Percent
VLBW

1.5 %

1.4 %

S.C. Percent
VLBW Neo.
Deaths

29.1 %

30.1 %

29.3 %

Percent S.C.
VLBW Births
In Community
Hospitals

31.0 %

28.4 %

26.5 %

Percent S.C.
VLBW Deaths
In Community
Hospitals

37.9 %

41.8 %

Percent
VLBW Neo.
Mortality in
Community
Hospitals

35.6 %

44.4 %

46.1 %

Percent
VLBW Neo.
Mortality in
Regional
Hospitals

26.2 %

24.5 %

23.2 %

TABLE 2.

For 1986, the VLBW neonatal mortality for
regional perinatal centers was 23.2% compared
to 46.1% for community hospitals
(X2:p<0.01).23

These data suggest that while a smaller pro-
portion of VLBW births were being delivered
in community hospitals, their mortality rates

increased. Futhermore, of the total VLBW
neonatal deaths in South Carolina, the propor-
tion contributed by community hospitals in-
creased over time.

DISCUSSION

These data demonstrate that infants with
birthweights between 501 and 1499 g have the
best chances for survival when delivered in a
regional perinatal center. During the time pe-
riod under study, neonatal mortality rates for
VLBW infants delivered in community hospi-
tals increased while mortality decreased for
VLBW infants delivered in regional perinatal
centers. This is more striking when one consid-
ers that there was an overall increase in the
proportion of VLBW births occurring in re-
gional centers. With more high risk births in
perinatal centers and fewer VLBW births in
community hospitals, it could be expected that
mortality rates in the community hospitals
would increase.

One explanation may be that many high risk
deliveries at community hospitals presented in
advanced stages of labor and could not be
transferred antenatally. If so, the number of
VLBW births remaining in community hospi-
tals could have been disproportionately com-

PERCENT OF S.C. VERY LOW BIRTH WEIGHT BIRTHS
AND NEONATAL DEATHS THAT OCCUR IN COMMUNITY
HOSPITALS; BY YEAR

Percent

-o- VLBW
Neonatal
Deaths

hi- VLBW Births

376

The Journal of the South Carolina Medical Association

REGIONALIZED PERINATAL CARE

VERY LOW BIRTH WEIGHT NEONATAL MORTALITY;
SOUTH CAROLINA; BY HOSPITAL TYPE

Percent

-e- Community
Hospitals

Regional

Hospitals

FIGURE III.

prised of particularly high risk deliveries. The
result of such a shift may have been fewer total
VLBW births (as observed) but an increase in
VLBW mortality (as observed). This the-
oretical shift, however, does not explain why
the percentage of total deaths contributed by
non-regional community hospitals did not de-
crease. In contrast, such a shift should have
resulted in a reverse trend.

An explanation may be that the VLBW de-
liveries transferred antenatally from commu-
nity hospitals to regional centers did not
contribute proportionately to the regional cen-
ter’s mortality rate. If mothers selected for
transport comprised the hardiest deliveries,
the effect could result in no additional mor-
tality in the regional center and a dispropor-
tionate contribution of total mortality from the
community. While there are no data to con-
firm the above, one possible explanation is that
non-regional centers were referring mothers at
high risk for VLBW deliveries, but low risk for
VLBW neonatal deaths. The patients remain-
ing at the non-regional center were at high risk
for both VLBW delivery and VLBW neonatal
death.

Regardless of the cause, the data indicate
that by 1986, community hospitals in South
Carolina experienced increasing VLBW neo-

natal mortality and contributed 41.8% of the
state’s total VLBW neonatal deaths in spite of
delivering only 26.5% of the total VLBW hos-
pital births (see Figure III). Community hospi-
tals appear to have begun to embrace the
concepts of regionalized perinatal care as evi-
denced by delivering fewer VLBW births. The
percentage decline in high risk deliveries is
suggestive of increased antenatal transfers for
deliveries of expected VLBW births. It is
hoped that this trend will continue with a resul-
tant reduction in neonatal mortality.

Early identification of risk status and the
commitment to antenatal transfers should sig-
nificantly increase survival in this group of
high risk babies. It is noted that any antenatal
referral of a high risk pregnancy must be ac-
companied by the acceptance of the referral at
a high risk institution. The involvement and
cooperation of at least two institutions is re-
quired for successful high risk referrals.

A second point is that determination of risk
status, antenatally, requires the availability of,
and access to, prenatal care. While the data
presented in this report grouped VLBW neo-
natal mortality rates by hospital of delivery,
regionalized perinatal care is evaluated by
more than the location of VLBW deliveries.
Community hospitals are critical to the success

August 1989

377

REGIONALIZED PERINATAL CARE

of regionalization by providing obstetric ser-
vices to low and intermediate risk patients and
accepting back transports from regional terti-
ary centers. By accepting intermediate and low
risk back transfers, high risk beds are available
for patients requiring tertiary care. Commu-
nity hospitals deliver the majority of births in
S.C.; over 65% of the total hospital births in

1986 were delivered in community hospitals.

From its early conception, regionalization
embodied the interworking relationships of ex-
isting health care systems into an approach
tailored to the needs of the patient and de-
signed to be cost effective. The future success
of the program depends on strengthening these
relationships. □

(S.

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We have DISPLAYED at every S.C. State Medical Society Meeting since 1921.
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378

The Journal of the South Carolina Medical Association

IV. REGIONALIZATION: A REVIEW OF THE ISSUES

The first three sections presented informa-
tion regarding regionalization efforts with a
focus on South Carolina. Unfortunately, few
published studies have targeted the results of
those activities. This final section will, there-
fore, focus on the highlights of the major pro-
gram components (Neonatal Intensive Care,
Maternal and Neonatal Transport, Cost Anal-
ysis, and Outreach Education) as evidenced
from reports from around the country. While
the most dramatic impact of regionalized per-
inatal care is measured in shifts in mortality
rates, regionalized perinatal care is much more
than specialized clinical care for high risk
mothers and newborns. It includes, in addition
to neonatal intensive care, high risk prenatal
care, maternal and newborn transport, cost
analysis, professional education, developmen-
tal follow up, research and ongoing evaluation
of all components.

NEONATAL INTENSIVE CARE

Perhaps the first goal of regionalized care
was to assure access to intensive care for all
high risk newborns. The improved outcome
documented among premature infants with ac-
cess to neonatal intensive care compared to
outcomes of those without the access of this
support confirms the wisdom of this objec-
tive.24’ 25 Studies of the effectiveness of inten-
sive care programs for newborns have clearly
indicated reduced birthweight-specific mor-
tality among high risk neonates bom in Level
III hospitals.

Cordero, et al. (1982) studied the neonatal
mortality of infants with birthweights between
500 and 1250 grams bom in the six hospitals in
Columbus, Ohio from 1 977 to 1 979, and found
a significant inverse relationship between the
hospital level of care (I, II, or III) at birth and
neonatal mortality rate. Examination of birth-
weight categories suggested that, regardless of
hospital level of care, neonatal mortality de-
creased with increasing birthweight. Com-
pared to Level III hospitals, however, Level I
and II hospitals demonstrated significantly
higher neonatal mortality rates for every birth-
weight group (see Table 3). The most striking
differences were observed in the 751-1000
gram group. Overall, the regional center expe-

rienced a 47% neonatal mortality for study
infants compared to 62% in the community
hospitals (p <0.01). 19 This is even more strik-
ing when one realizes that in 1 979, private neo-
natologists were located in two of the five non-
university hospitals in Columbus.

This investigation suggests increased sur-
vival for very low birthweight infants bom in a
tertiary care hospital. The authors concluded
‘Our data in regard to survival of the pre-
mature infants under 1,250 gm show that 15%
more infants would have survived if they had
been delivered at the regional perinatal
center.’19

Other investigators have demonstrated sim-
ilar results.18- 26-30 Gortmaker, et al. (1985)
found a significantly greater rate of survival at
96 hours after birth for Level III inborn very
low birthweights infants. This study examined
53,948 births over a two-year period for four
states. These patterns of survival remained
after controlling for hospital differences in
birthweight distribution, race, gestational age,
and multiple births.14 Williams (1979) found
hospital level of care was a more important
predictor of survival, than medical or so-
cioeconomic measures, in his review of over
three million live births in California.17

TABLE 3

Mortality Rates by Birth W eight Groups and
Level of Hospital of Delivery

Total

500-7 50g 75 1-1000 g 1001-1250g 500-1250g

Level I, II Hospitals 97% 71% 33% 62%

Level III Hospitals 84% 56% 24% 47%

These studies are representative of a much
larger body of literature. Whether using rela-
tively small hospital records data sets or large
vital records data sets, the results are consis-
tent. Very low birthweight infants born in hos-
pitals with neonatal intensive care units have a
significantly greater chance for survival than
do similar infants bom in Level I or II hospi-
tals. This trend remains even after controlling
for the differences in the populations (demo-
graphic, health, etc.) served by individual
hospitals.

August 1989

379

REGIONALIZED PERINATAL CARE

NEONATAL TRANSPORT

While it is not possible for all high risk new-
borns to be delivered in a regional center, the
literature suggests increased survival may be
possible by utilization of perinatal transport
systems. Of very low birthweight newborns de-
livered in community hospitals, those selected
for transport have lower mortality rates than
those remaining in the hospital of birth. 18> 19

Cordero et al. ( 1 982) found that among those
very low birthweight infants (< 1 500gm) born
in Level I or II hospitals, non-transported in-
fants experienced 26% higher mortality than
infants who were subsequently transported to
the regional center.18

Transported infants as a group are highly
selected, and those clinically thought to have
minimal chances of survival may not be trans-
ported. A study by Sachs (1983), found that
survival of extremely low birthweight
(<1000gm) transported infants was higher
than similar infants delivered in the tertiary
center (suggesting a selection bias among the
smallest infants). Transported infants with
birthweights greater than 1000 gm had sur-
vival rates lower than similar infants delivered
in the tertiary center. In addition, the survival
of transported infants was directly propor-
tional to the distance transported. Survival of
infants transported from hospitals located
nearby was less than that for infants trans-
ported from hospitals located farther away.30

The literature on the effectiveness of trans-
port has been criticized because of the poten-
tial selection bias among those transported.31
While the quality of the transport services also
influences survival, its effect can only be dem-
onstrated on infants that survive long enough
to be transported, and are anticipated to ulti-
mately survive. Deaths in the first hours of life
may more closely reflect skills in intrapartum
management, neonatal resuscitation, and
stabilization.

Paneth et al. (1984), examined the neonatal
mortality of all low birthweight (501-2250 gm)
singletons delivered in each of the three hospi-
tal levels of newborn care in New York City
(N= 13,560). Fourteen maternity services
were classified as Level III (4598 births), 20 as
Level II (5857 births), and 32 as Level I (3105
births).

Infants delivered in Level I and Level II

units had similar overall neonatal mortality
and these death rates were significantly higher
than the corresponding rates at Level III units
(p<0.05). Ninety-five percent of the deaths
which occurred in the first four hours of life, for
both Level I and II, occurred in the hospital of
birth. After the first four hours, the place of
death was distinctly different for Level I and
Level II births.

Within four hours of birth, Level I hospitals
had the highest mortality rate among infants
with birthweights less than 1251 grams
(68/1000). At about 18 hours of age, however,
the survival curves of Level I and Level II
births intersect. By 28 days, survival at Level I
units was higher than that at Level II and
closely approached that for Level III. This ef-
fect was not evident for heavier birthweights
(1251-2250 grams).

The authors adjusted the mortality rates for
the distribution of birth weight, gestational
age, race, sex, mother’s age, parity, education,
marital status, type of financing, complica-
tions of pregnancy and inadequacy of prenatal
care. After controlling for these differences
across hospitals, the results were unchanged.

In the discussion, Paneth et al. suggested that
deaths within the first four hours of life con-
stituted a component of perinatal mortality
that could not be influenced by infant trans-
port and reflected clinical management.32
These data, with those of others, strongly sup-
port the concept of antenatal transport for high
risk deliveries and suggest there is a limit to the
benefit of neonatal transport in affecting over-
all mortality.33’ 34

MATERNAL TRANSPORT

Harris et al., examined antenatal (N = 285)
and neonatal (N=776) transports received by
a single tertiary center over a three-year period.
Of total transports, antenatal transports in-
creased from 5.5% to 34.7% over the study
period. Newborns of antenatal transports had
significantly lower neonatal mortality than
neonatal transports (p<0.0001). Fewer an-
tenatal transports required continuous posi-
tive airway pressure (p<0.0005) and inter-
mittent positive pressure ventilation
(p<0.0001) than neonatal transports. In addi-
tion, hospital length of stay was significantly
shorter for antenatal transports (pcO.OOOl).35

380

The Journal of the South Carolina Medical Association

REGIONALIZED PERINATAL CARE

Other researchers have reported similar re-
sults.36'37 Although subtle differences exist due
to study design, population selection, etc., the
findings suggest lower mortality rates, lower
measures of morbidity and reduced utilization
of health care resources for the antenatal refer-
ral compared to the neonatal referral.

COST ANALYSIS

Research into the cost effectiveness of re-
gionalization is notably lacking. There are in-
vestigations into the costs incurred with hav-
ing a child in newborn intensive care as well as
costs incurred with rearing a child with neu-
rologic and developmental sequelae.38'39 Un-
fortunately, little work has focused on the
resource savings from perinatal regionali-
zation.

Finkler (1979) examined the cost effective-
ness of regionalization using open-heart sur-
gery as an example. His analysis should closely
parallel the perinatal example in theory. He
noted that for certain specialized services, sav-
ings would occur by utilizing centralized facili-
ties. “A major contributing factor to increasing
hospital costs is the duplication of expensive
capital equipment and highly trained man-
power for the provision of infrequent, but
highly specialized services.”40

Knox, et al. (1983) described a collaborative
association between a Level II hospital and a
regional Level III Perinatal Center which ulti-
mately resulted in a substantial reduction in
costs for the Level II nursery. By utilizing the
center’s personnel as consultants, identifying
the patient risk status appropriate for each
facility, establishing training needs and re-
sponsibilities, formulating quality review pro-
cedures and creating staffing privileges, both
the regional center and the community hospi-
tal were able to increase census, reduce mor-
tality, increase hospital revenues and decrease
patient costs.41 Since this high-tech expensive
care is required by a minority of the newborns,
consolidation into regional centers becomes
cost effective, especially in the current en-
vironment of limited health care resources.

OUTREACH EDUCATION

One component of a coordinated system of
care which distinguishes a tertiary care center
from a regional perinatal center is the provi-

sion of continuing professional education. Ap-
proaches include: (1) professionals from the
regional center travel to the referring hospital
and offer lectures, demonstrations, and case
studies; (2) staff from community hospitals
have a ‘hands-on’ training component in some
regional centers to facilitate learning and up-
dating intermediate care skills; (3) a one to
three-day seminar, held in the regional center,
offers an array of lectures explaining various
policies, procedures, etc.; and, (4) a formal self-
paced series of topics, guided by the regional
center staff, are provided to the staff of the
community hospital. It is this last approach
that has received increased attention from
those seeking to evaluate the efficacy of con-
tinuing educational programs.

Lazzara, et al. (1982) found a significantly
lower incidence of subependymal and/or intra-
ventricular hemorrhage (SEH/IVH) in trans-
ported infants (birthweights < 1,701 gm) from
a group of hospitals participating in outreach
education compared to nonparticipants (p <
0.05). One group participated in the regional
center’s continuing educational program and
the second group did not. There was no dif-
ference between hospital groups in incidence
of low Apgar scores, birthweight, gestational
age, interval between birth and transport team
arrival, incidence of hyaline membrane dis-
ease, use of volume expanders, and use of bi-
carbonate. In addition, participating hospitals
more adequately prepared children for trans-
port than did nonparticipating hospitals.42
Other investigators have reported similar re-
sults.43’ 44

IMPACT

The overall impact of regionalized care and
its effects have been measured in a variety of
ways. Several investigators have attempted to
measure the extent of regionalization in an
area and its cumulative impact by targeting net
overall mortality over time.

Goldenberg et al. (1985) compared mortality
rates for pre-regionalization to mortality rates
for post-regionalization in Alabama. During
the period of study twice as many infants
weighing between 1000 and 2500 grams deliv-
ered in perinatal centers. This was accom-
panied by a decline in the neonatal mortality
by approximately one-third across all birth-

August 1989

381

REGIONALIZED PERINATAL CARE

weight groups. The majority of reduction in
neonatal mortality occurred in the very low
birthweight infants. This study suggested that
regionalization resulted in shifts toward
greater very low birthweight deliveries in re-
gional centers and lower overall mortality
rates.45 Other measures of the extent of region-
alization have demonstrated similar shifts in
birthweight distributions specifically as a re-
sult from antepartum transports.46

Still other authors have measured changes in
cause of death.47 Hein and Lathrop ( 1 986) clas-
sified causes of neonatal mortality into either
non-preventable (congenital malformations,
extremely low weight, etc.) or preventable
(necrotizing enterocolitis, birth asphyxia, in-
traventricular hemorrhage, persistent fetal cir-
culation). They noted a shift in cause of death
from primarily preventable causes pre-region-
alization to non-preventable causes post-re-
gionalization with the largest reductions noted
in Level I hospitals.48

A controversy that remains concerns wheth-
er the reduction in neonatal mortality demon-
strated by the regional centers is actually
increasing the population of children with se-
vere handicaps who would have previously
died. More pointedly, does such aggressive
management of the newborn salvage a greater
proportion of severely impaired infants there-
by placing an increasing emotional and finan-
cial burden on the family and society?

Current research does not substantiate this
criticism. McCormick et al. (1985) found that
although changes in mortality have resulted in
an increased survival of low birthweight and
very low birthweight infants, no increases in
the proportion of surviving infants with mor-
bidity related to antenatal and intrapartum
events has been observed.49 Other researchers
have reported similar findings.50'52

A series of studies in Canada suggests a dif-
ferent assessment may be required. In Toronto,
prior to 1970, 75% of all infants whose birth-
weights were less than 1000 grams died and
only 15% survived as normal children. In
1974, at the same hospital, mortality was de-
creased to 53%. Of the survivors, 33% had no
handicaps.34 More recently, 48% of infants less
than 1000 grams have had no handicaps with
22% having severe functional handicaps and
29% with moderate or mild handicaps on fol-

low-up. It should be noted that morbidity was
less common (15.5%) for infants born in terti-
ary centers compared to infants born
elsewhere.53

From more recent morbidity data, a greater
percentage of high-risk neonates are found to
have normal intelligence on follow-up in re-
cent years. However, there is still a substantial
number of children who are later found to be
neurologically impaired. Although the propor-
tion of infants with handicaps is not increas-
ing, the absolute number of handicapped
survivors may be increasing due to decreasing
mortality rates. In order to access future mor-
bidity trends and to improve our prognostic
ability, a continuing emphasis upon develop-
mental follow-up of newborn intensive care
survivors is required.

CONCLUSION

In conclusion, examination of the various
components of perinatal regionalization sug-
gests regional centers must become involved in
the full array of patient care services to achieve
maximal impact. Each activity, in its own
right, contributes to the comprehensive devel-
opment of systems coordination toward a
common goal. This goal or cumulative end-
point is the reduction in perinatal mortality
rates achieved through risk appropriate care
(antepartum, intrapartum, postpartum) in the
most cost effective manner. It should be re-
membered that most babies can be born in a
Level I or II hospital provided a normal out-
come is expected. Voluntary referral of high-
risk maternal and newborn patients to Level
III perinatal centers will continue to be neces-
sary to assure optimal outcomes. As Grassi
(1988) stated, “Regionalization has proven to
be effective in organizing and orchestrating
perinatal and neonatal care delivery by ensur-
ing quality of services, access, economic costs,
and optimal outcome in a cost effective
manner.”54

The concept of perinatal regionalization was
started on a voluntary basis with some infu-
sion of public funds needed to support systems
aspects of regional care. The results have led to
a decline in maternal and infant morbidity and
mortality as reviewed.

The 1980s, however, have seen two signifi-
cant changes in the national healthcare system.

382

The Journal of the South Carolina Medical Association

REGIONALIZED PERINATAL CARE

First, many Level III hospitals have incurred
significant costs in the care of indigent high-
risk mothers and infants with concurrent
losses in reimbursement for care. This has
strained hospital resources resulting in cost
shifting to other inpatients with medical insur-
ance. Second, there is more competition for
patients between hospitals which has resulted
in less willingness to refer high-risk patients
from Level I or II hospitals to the regional
perinatal center. In fact, many hospitals have
come under an imperative to market the abil-
ity to provide high-risk care, sometimes du-
plicating services.

REFERENCES

1. Hess, J.H., Premature and Congenitally Diseased In-
fants, Lea and Febinger, Eds., Philadelphia, 1922.

2. Hess, J.H., Heated Bed for Transportation of Preterm
Infants, Journal of the American Medical Association
80(18), 1313, 1923.

3. Air Conditioning for Preterm Infants, Editorial, Jour-
nal of the American Medical Association, 95( 15), 11 00,
1930.

4. Towards Improving the Outcome of Pregnancy. Com-
mittee on Perinatal Health, White Plains, New York:
The National Foundation — March of Dimes, 1976.

5. Standards and Recommendations for Hospital Care of
Newborn Infants. Committee on Fetus and Newborn,
American Academy of Pediatrics, Evanston, 111.

6. Guidelines for Perinatal Care, American Academy of
Pediatrics and The American College of Obstetricians
and Gynecologists. The National Foundation —
March of Dimes, Second Ed., 1988.

7. South Carolina Regionalization of Perinatal Health
Care, South Carolina Department of Health and En-
vironmental Control, E.K. Aycock, Commissioner,
November, 1974.

8. Heins, H.C., South Carolina’s Perinatal Health, The
Journal of the South Carolina Medical Association,
71(8) 239-242, 1975.

9. Lynch, K.M., and Heins, H.C., S.C. Department of
Health and Environmental Control’s Perinatal Pro-
gram, The Journal of the South Carolina Medical Asso-
ciation, 72(6) 211-212, 1976.

10. Guidelines for Achieving Perinatal Health in South
Carolina, South Carolina Perinatal Association, Oc-
tober, 1980.

11. Perinatal Health Services Assessment, Governor’s
Council on Perinatal Health, December, 1983.

12. Perinatal Plan of Action, Governor’s Council on Per-
inatal Health, April, 1984.

1 3. Hein, H.A. and Lathrop, S.S., The Changing Pattern of
Neonatal Mortality in a Regionalized System of Per-
inatal Care, American Journal of Diseases in Child-
hood, 140:989-993, 1986.

14. Gortmaker, et al., The Survival of Very Low Birth-
weight Infants by Level of Hospital of Birth: A Popula-
tion Study Of Perinatal Systems in Four States,
American Journal of Obstetrics and Gynecology,
152(5):5 17-524, 1985.

In the future, quality perinatal programs
must prove that they are not only efficient but
also cost effective. The relationships between
Level I and II hospitals and the regional per-
inatal center need to be improved. Referral of
mothers and babies to the appropriate level of
care must be encouraged solely on the basis of
health risk.

Future efforts must continue to encourage
and support active participation from physi-
cians and hospitals in South Carolina’s current
efforts toward regionalized perinatal care. Sig-
nificant reductions in mortality can and will be
achieved through such activities. □

15. Grassi, L.C., Life, Money, Quality: The Impact of
Regionalization on Perinatal/Neonatal Intensive
Care, Neonatal Network, 53-59 February, 1988.

16. Walker, D.B., Vohr, B.R., and Oh, W., Economic
Analysis of Regionalized Neonatal Care for Very Low-
Birthweight Infants in the State of Rhode Island, Pedi-
atrics, 76(1): 69-74, 1985.

1 7. Williams RL: Measuring the effectiveness of perinatal
medical care. Medical Care, 1 7(2):95-l 10, 1979.

1 8. Paneth N, et al.: Newborn intensive care and neonatal
mortality in low birthweight infants. N. Engl. J. Med.
307:149-155, 1982.

19. Cordero L, et al.: Very low birth weight infant: I.
Influence of place of birth on survival. American J. of
Obstet. & Gyn 143:5 533-537 1982.

20. Verloove-Vanhorick, et al.: Mortality in very preterm
and very low birth weight infants according to place of
birth and level of care: results of a national collab-
orative survey of preterm and very low birth weight
infants in the Netherlands. Pediatrics 8 1 (3):404-4 1 1
1988.

2 1 . Statistical Report Series, SRS-0007-0885; Birthweight-
Specific Neonatal and Fetal Mortality by Hospital;
South Carolina Department of Health and Environ-
mental Control, Office of Vital Records and Public
Health Statistics; 1984.

22. Statistical Report Series, SRS-00 14-1 286; Birthweight-
Specific Neonatal and Fetal Mortality by Hospital;
South Carolina Department of Health and Environ-
mental Control, Office of Vital Records and Public
Health Statistics; 1985.

23. Statistical Report Series, SRS-00 1 1 -0887; Birth weigh t-
Specific Neonatal and Fetal Mortality by Hospital;
South Carolina Department of Health and Environ-
mental Control, Office of Vital Records and Public
Health Statistics; 1986.

24. Thompson, M., and Khot, A. ‘Impact of Neonatal
Intensive Care,’ Archives of Disease in Childhood,
60:213-214, 1985.

25. Kitchen, W., and Campbell, D. ‘Controlled Trial of
Intensive Care for Very Low Birth Weight Infants,’
Pediatrics, 48(5):71 1-714, 1971.

26. Bowes, W. ‘A Review of Perinatal Mortality in Colo-
rado, 1971-1978, and its Relationship to its Region-
alization of Perinatal Services,’ American Journal of
Obstetrics and Gynecology, 141(8): 1045-1052, 1981.

August 1989

383

REGIONALIZED PERINATAL CARE

27. Nugent, R. ‘Perinatal Regionalization in North Caro-
lina, 1967 and 1979: Services, Programs, Referral Pat-
terns, Perinatal Mortality Rate Declines for Very Low
Birthweight Infants,’ North Carolina Medical Journal,
43(7): 5 1 3-5 1 5, 1982.

28. Goldenberg, R. et al., ‘Infant Mortality: The Rela-
tionship Between Neonatal and Post Neonatal Mor-
tality During a Period of Increasing Perinatal Center
Utilization,’ Journal of Pediatrics, 106(2):301-303,
1985.

29. Paneth, N., et al., ‘Medical Care In Preterm Infants of
Normal Birthweight,’ Pediatrics, 77(2): 158-1 66, 1986.

30. Sachs, B. ‘Neonatal Transport in Georgia: Implica-
tions for Maternal Transport in High Risk Pregnan-
cies,’ Southern Medical Journal, 76(1 1):1397-1 400,
1983.

31. Hoekstra, R., et al., ‘In Utero Versus Neonatal Trans-
portation of High Risk Perinates: A Comparison,’
Minnesota Medicine, October, 1981.

32. Paneth, N., Kiley, J., and Susser M. ‘Age at Death
Used to Assess the Effect of Inter-Hospital Transfer of
Newborns,’ Pediatrics, 73(6):854-861, 1984.

33. Modanlou, H., et al., ‘Antenatal Versus Neonatal
Transport to a Regional Perinatal Center: A Com-
parison Between Matched Pairs,’ Obstetrics and
Gynecology, 53(6):725-729, 1979.

34. Modanlou, H., et al., ‘Perinatal Transport to a Re-
gional Perinatal Center in a Metropolitan Area: Mater-
nal Versus Neonatal Transport,’ American Journal of
Obstetrics and Gynecology, 1 38(8): 1 1 57-1 1 64, 1980.

35. Harris, B. ‘In-utero Versus Neonatal Transportation
of High Risk Perinates: A Comparison,’ Obstetrics and
Gynecology, 57(4):496-499, 1981.

36. Crenshaw, C. ‘Prematurity and the Obstetrician: A
Regional Neonatal Intensive Care Nursery is Not
Enough,’ American Journal of Obstetrics and Gyne-
cology, 147(2): 125- 132, 1983.

37. Merenstein, G., et al., ‘An Analysis of Air Transport
Results in the Sick Newborn II. Antenatal and Neo-
natal Referrals,’ American Journal of Obstetrics and
Gynecology, 128(5):520-525, 1977.

38. Shankaren, S. ‘Medical Care Costs of High Risk In-
fants After Neonatal Intensive Care: A Controlled
Study,’ Pediatrics, 81(3):372-378, 1988.

39. Pomerance, J. ‘Cost of Living Per Infants Weighing
1000 Grams or Less at Birth,’ Pediatrics, 61(6):
908-910, 1978.

40. Finkler, S. ‘Cost Effectiveness of Regionalization: The
Heart Surgery Example,’ Inquiry, 16:264-270, 1979.

41. Knox, G., et al., ‘Regionalization Pact Increases Reve-
nue,’ Hospitals, 2:38, 1983.

42. Lazzara, A., et al., ‘Continuing Education in the Com-
munity Hospital and Reduction in the Incidence of
Intracerebral Hemorrhage in the Transported Preterm
Infant,’ Journal of Pediatrics, 1 0 1 (5):757-76 1 , 1982.

43. Kattwinkel, J., et al., ‘Improved Perinatal Knowledge
and Care in the Community Hospital Through a Pro-
gram of Self Instruction,’ Pediatrics, 64(4):45 1-458,
1979.

44. Kattwinkel, J. ‘Perinatal Outreach Education: A Con-
tinuation Strategy for Basic Program,’ American Jour-
nal of Perinatology, l(4):335-340, 1984.

45. Goldenberg, R. ‘Vital Statistics Data as a Measure-
ment of Perinatal Regionalization in Alabama,
1970-1 980,’ Southern Medical Journal, 78(6):657-660,

1985.

46. Powers, W., Hedgewood, P. and Kim, Y. ‘Perinatal
Regionalization as Measured by Antenatal Referral,’
Obstetrics and Gynecology, 71(3):375-379, 1988.

47. Ohlsson, A., Shennan, A. and Rose, T. ‘Review of
Causes of Perinatal Mortality in a Regional Perinatal
Center, 1980-1984,’ American Journal of Obstetrics
and Gynecology, 157(2):443-445, 1987.

48. Hein, H. and Lathrop, S. ‘The Changing Pattern of
Neonatal Mortality in a Regionalized System of Per-
inatal Car t,' American Journal of Diseases in Children,
140:989-993, 1986.

49. McCormick, M., Shapiro, S. and Starfield, B. ‘The
Regionalization of Perinatal Services: Summary of the
Evaluation of a National Demonstration Program,’
Journal of the American Medical Association, 253(6):
799-804, 1985.

50. Seigel, E., et al., “Controlled Evaluation of Rural Re-
gional Perinatal Care: Developmental and Neurologic
Outcomes at One Year,’ Pediatrics, 77(2): 187- 195,

1986.

51. Horwood, S. ‘Mortality and Morbidity of 500-1499
Gram Birth Weight Infants Livebom to Residents of a
Defined Geographic Region Before and After Neo-
natal Intensive Care,’ Pediatrics, 69(5):6 13-620, 1982.

52. Pape, K., Burlis, R., Ashby, S., et al., ‘The Status of
Two Years of Low Birthweight Infants Bom in 1974
With Birthweights of Less Than 1001 Grams,’ The
Journal of Pediatrics, 92:253-260, 1978.

53. Kitchen, W., Ford, G., Orgill, A., et al., ‘Outcome in
Infants With Birthweights 500 to 999 Grams: A Re-
gional Study of 1979 and 1980 Births,’ The Journal of
Pediatrics, 104:921-927, 1984.

54. Grassi, L. ‘Life, Money, Quality: The Impact of Re-
gionalization on Perinatal/Neonatal Intensive Care,’
Neonatal Network, 2:53-59, 1988.

384

The Journal of the South Carolina Medical Association

Editorial

Dr. Sasser’s address before the House of Delegates at this year’s annual meeting drew wide
admiration, prompting its publication here in its entirety.

Guest editorials reflect the opinion of the author and do not necessarily reflect the opinion of the
Editorial Board or the leadership of the South Carolina Medical Association.

— CSB

THE ESSENTIAL HEALER

What if you could take away all the contem-
porary trappings of medical practice?

What if you could take away the third party
invasion that swirls around us, confusing and
complicating every step of the therapeutic en-
counter between doctor and patient?

What if you could take away the confound-
ing burden of governmental regulation that
defines and directs every clinical and moral
decision we make on behalf of those for whom
we care?

What if you could take away the explosion of
technology that, wiiile opening up endless vis-
tas for progress, overwhelms us with its insatia-
ble need for knowledge and expertise and
enslaves us with its mandate for use, while
filling our lives with apparently unsolvable
moral dilemmas?

What if you could take away: our guilt for
helping to create the most expensive health
care system in the w'orld which still fails to
provide access to care for a third of its people;
our anxiety over the constant threat of litiga-
tion that drives us to practice a kind of defen-
sive medicine which seems, at times, insane;
our greed, that leads us to decry a reimburse-
ment mechanism which distributes health care
dollars in idiotic ways, and then to turn around
and charge $200.00 or $2,000.00 for a 30-min-
ute procedure, and then justify that charge on
the basis that the very same idiotic reimburse-
ment mechanism we so loudly condemn will
pay it?

Well, we spend much of our energy and time
each day with these issues, but for the next 1 5
minutes, I would like for you to put them aside.

To do this, I want you to take one minute to
close your eyes and relax — now' visualize a
very nice file cabinet. Now take each one of
these issues and place them in a manila folder:
first, the third parties; then government regula-
tions; now technological advances; now mis-
cellaneous aggravations of modem medicine.
Put them each in their appropriate file and
place them in the drawer. They will be safe
there and you can come right back to them in
just a few' minutes. But for now, you will put
them away in a safe place. Now open your eyes.
It is important to put all these issues and feel-
ings aside because what I want to talk about is
the nature of medicine without the ornamenta-
tion.

For if w'e could take all of this aw^ay, what
would be left? What is it that is truly unique
about being a healer? What is so special about
us, about what we do? This is more than just a
rhetorical question, because, like never before
it’s so easy to see; the trappings that help iden-
tify the physician of the ’80s are already disap-
pearing. You know as well as I that the
superstructure of medicine that I encountered
in internship in 1967 is long gone — And guess
what? That of the ’80s will go much faster.
None of these things are permanent aspects of
wfiat we do and wiio we are. What is perma-
nent is those things that healers of every
culture have been doing for thousands of years.
What are our special gifts? They are indeed
gifts and as we identify them, bring cause for
celebration.

First and foremost among our gifts is the
awareness that w'e are not ourselves healers:

August 1989

389

THE ESSENTIAL HEALER

only instruments. The more we explore the
mysteries of life, the more we come to marvel
at the incredible power of the human body to
heal itself. Only from our perspective, that of
the medical scientist, can it be fully appreci-
ated, that more and more our technical skills
are being employed to harness and unleash
healing potential already in place. And as we
are filled with awe over the creation, the de-
sign, we are led to look beyond, in even greater
wonder, to the Creator; the Designer. The
writer of the 139th Psalm, writing specifically
for the modern scientist, says it like this: “You
made all the delicate inner parts of my body
and knit them together in my mother’s womb.
Thank You for making me so wonderfully
complex. It is amazing to think about. Your
workmanship is marvelous — and how well I
know it. You were there while I was being
formed in utter seclusion!”1 Another transla-
tion says: “I will praise thee; for I am fearfully
and wonderfully made.”2
Secondly, this awe grows as we recognize our
place in the design, our own divine calling, our
“Vocatio Dei.” Not everybody can do what we
do. Not everyone receives a divine call to be a
healer. But that divine call doesn’t often take
the form of a “Burning Bush” or a “Damascus
Road” experience. In fact, it more often is just
the opposite kind of call. For example, I de-
cided I had what it takes to be a doctor when
my brother invited me down for a medical
school weekend. He showed me through the
anatomy lab at MUSC and I didn’t throw up,
then took me to one of the wildest parties I
have ever seen and I thought “Hey, I can han-
dle this!” But why are you a doctor? What
really brought you here? Was it a pathological
rescue neurosis? Does it irritate you when
someone pays you for your advice and then
refuses to take it? It does me. Was it fear of
dying? You know most health professionals
score high on this in psychological testing, the
theory being that we can maintain the illusion
of control over our own mortality by exercising
some control over that of others. This was high
on my agenda. In fact, I have already informed
my family that my tombstone epitaph should
read: “He went out kicking and screaming and
was an embarrassment to us all.” Was it greed?
You read the poll where, in some specialties,
fully half the docs were advising their children

not to go into medicine, because “it’s not worth
the money.” I know it’s more complex than
this but I must confess to you that the idea of a
financially secure future was certainly a big
motivator for me. What personal psycho-
pathology drew you to such a noble profession?

But don’t get me wrong. I don’t say this to
inflict guilt; just the opposite. You see, it is so
freeing to realize that it is not out of our perfec-
tion that we are called to be special, but our
imperfection; for in each of us there exists a
deep yearning to be whole. And it is just this
yearning that draws us into endeavors de-
signed to promote self-healing.3 It’s as though
God has called us into medicine just so we will
be forced to heal those parts of our personhood
that most need it. For in medicine we will have
to come to terms with our rescue pathology or
go nuts! In medicine our daily confrontation
with the dying — especially when our patients
become our friends — will break down our de-
nial and force us to face our own mortality; and
the practice of medicine will force us to con-
front our own greed, by placing in our care
some of the most abject, dismally poor
wretches on this earth. St. Augustine put it this
way: “Thou movest men to praise Thee, for
Thou has’t made us for Thyself and our hearts
are restless until they rest in Thee.”4 It is in this
manner that we are drawn by our personal
imperfections toward self-healing.

And so, likewise, we are led to celebrate a
third special gift: our woundedness. For over
generations and cultures, it is the wounded
healer to whom is given the power to heal. This
principle is often overlooked and under-appre-
ciated in our success-oriented society. It is,
likewise, a complex one and rather than go into
detail, I will instead give three illustrations
which I think will be helpful. There is a legend
in the Talmud about a Rabbi who asked the
prophet Elijah when the Messiah would come.
Elijah replied that the Rabbi should ask the
Messiah directly and that he could find Him
sitting at the gates of the city. “How will I know
Him?” the Rabbi asked. Elijah replied: “He is
sitting among the poor covered with wounds.
The others unbind all their wounds at the same
time and wait for someone to come and bind
them up again. But He unbinds one at a time
and binds it up again, saying to Himself: ‘per-
haps I shall be needed: if so I must always be

390

The Journal of the South Carolina Medical Association

THE ESSENTIAL HEALER

ready so as not to delay for a moment.’ ”5
Another example comes from Second Corin-
thians. Here, Paul is talking about a personal
affliction he euphemistically calls “a thorn in
my side.” We don’t know what the thorn is.
Possibilities include blindness from trachoma,
epilepsy or depression. In any case, he has
prayed repeatedly to have God take away the
thorn and, in God’s refusal to do so, Paul
discovers a timeless truth which might be
termed “the paradox of power.” Paul writes:
“Three different times I begged God to make
me well again. Each time He said, ‘No. But I
am with you: that is all you need. My power
shows up best in weak people.’ ”6
A third example of the power of healing
inherent in our woundedness comes from a
one act play by Thornton Wilder called “The
Angel Who Troubled The Waters.” It’s based
on the story of the lame man and Jesus by the
pool of Bethesda in the Gospel of John. A
legend of the times had it that the first ripple of
the waters by the wind in the morning was an
Angel of the Lord passing over the pool and the
first person to bathe in the pool after the ripple
occurred would be healed. As a result, a great
number of lame, blind and chronically ill peo-
ple would come to the edge of the pool and wait
for the water to move. Jesus discovers a man
who has been lying there for some 38 years,
probably his entire life. When Jesus asks him if
he really wants to be healed, the man com-
plains that no one will help him get into the
pool first after the water is troubled, and some-
one else always gets there before him. Jesus
tells the man that perhaps he should begin
taking some responsibility for his own life, and
the man is miraculously healed. Wilder’s play
is about a physician, broken by the endless
tragedies of his own life, as well as those of his
patients, who comes to the pool to be healed of
his depression and guilt. The angel appears but
blocks the physician just as he is ready to step
into the water and be healed.

Angel: Draw back, physician, this mo-
ment is not for you.

Physician: Angelic visitor, I pray thee, lis-
ten to my prayer.

Angel: Healing is not for you.

Physician: Surely, surely, the angels are
wise. Surely, O Prince, you are not deceived
by my apparent wholeness. Your eyes can

see the nets in which my wings are caught;
the sin into which all my endeavors sink
half-performed cannot be concealed from
you.

Angel: I know. . . .

Physician: Oh, in such an hour was I bom.
and doubly fearful to me is the flaw in my
heart. Must I drag my shame, Prince and
Singer, all my days more bowed than my
neighbor?

Angel: Without your wound where would
your power be? It is your very remorse that
makes your low voice tremble into the hearts
of men. The very angels themselves cannot
persuade the wretched and blundering chil-
dren on earth as can one human being bro-
ken on the wheels of living. In Love’s service
only the wounded soldiers can serve. Draw
back.7

It is this very woundedness, this neurotic
need we have to seek healing in the process of
facilitating the healing of others, that calls us
out in the night, that drives us through our
fatigue, that provides us with the courage to
deliver the worst of news, that gives us the
strength to share in the suffering of so many.
“My power shows up best in weak people.”
There are several other characteristics pecu-
liar to our vocation, such as our specialized
ability to bond to our patients as a healing
agent,8 and our ability to help our patients find
meaning to their pain and suffering;9 but a final
gift I would like to mention, which may be a
part of every profession, not just medicine, is
the gift of healing we can bring to each other,
our colleagues. Now this is one I know a lot
about. You see, I was sued for malpractice a
few years ago. Now I don’t know how your
lawsuit affected you, but I was devastated, an
emotional trauma surpassed only by the sud-
den death of my father when I was 1 1. Well,
I’m in a group of four internists whose practice
dates back to 1948. We are, sort of, the Smith-
Barney of Conway: venerable, respected, very
conservative. The other thing is, this was not a
case of a plaintiff unhappy over an unsatisfac-
tory outcome. The truth is, I blew it and it
reflected on us all. But those guys cared so
much for me; hardly a day passed when one of
them didn’t stop by after work to check on me,
to commiserate with me, and to affirm me.
Time and again, they made extra efforts to

August 1989

391

THE ESSENTIAL HEALER

point out things I was doing that were good,
and thus rub my badly damaged perspective
and self-concept with a healing balm. In this
way they surrounded me with an atmosphere
of Grace, and let me know that I was loved and
forgiven and valuable. We are the only ones
who can do this for each other, you know, for
we are the only ones who truly understand.

And so, as we continue our struggles with the
vitally important, yet perishable aspects of our
medical practices, try to remember, and hold
on to, those qualities that are permanent and
lasting. Try to remember our special vantage
point that helps us marvel at the miracle of
healing as no one else can; try to remember the
nature of our Divine Calling, a call to whole-
ness. Try to remember the paradoxical power
of healing inherent in our woundedness, that
leads us to celebrate our human frailties; and
try to remember that special gift we are given,
the ability to bring healing to each other.

I would like to close with a prayer from the
Aztec Indians.

Only for so short a while, O God,

You have loaned us to each other,
because we take form

in Your act of drawing us,

And we take life

in Your painting us,

And we breathe

in Your singing us.

But only for so short a while
have You loaned us to each other.

AMEN.

Charles G. Sasser, M.D.

8002 Myrtle Trace Dr.

Conway, S. C. 29526

REFERENCES

1. Psalm 139:13-16. Living Bible.

2. Psalm 139:14. Revised Standard Version.

3. Suchman, A.L.; and Matthews, D.A. “What Makes the
Patient-Doctor Relationship Therapeutic? Exploring
the Connexional Dimension of Medical Care,” Annals
of Internal Medicine 1988;108:125-130.

4. Knight, J. A. “The Minister as Healer, the Healer as
Minister,” Journal of Religion and Health, 1982, Vol.
21, 107.

5. Nouwen, H. J. The Wounded Healer — Ministry in
Contemporary Society. Garden City, N.Y., Doubleday
and Company, Inc. 1972.

6. II Corinthians 12:7-9. Living Bible.

7. Wilder, T.N., The Angel That Troubled the Waters and
Other Plays. New York, Coward — McCann, 1928,
145-149.

8. Cassell, E. J. The Healer’s Art: A New Approach to the
Doctor-Patient Relationship. J. B. Lippincott, New
York, 194.

9. Ibid, 212.

392

The Journal of the South Carolina Medical Association

On the Cover

HOSPITAL DELIVERY ROOM: CIRCA 1930

This month’s cover pictures a “state-of-the-
art” hospital delivery room, circa 1930. Ni-
trous oxide was the choice for control of pain,
although chloroform, ether, twilight sleep,
and/or barbiturates were also used. One un-
pleasant result of the use of chloroform in a
room lighted by gas was the formation of chlo-
rine gas which caused “paroxysms of cough-
ing” in the attendants to delivery. The patient
usually escaped this problem since she was
anesthetized to such a degree that the irritating
effect of the chlorine was unnoticed. In the
days before air conditioning, the windows of
the delivery' room were usually left open in the
summertime. On the hottest of days, blocks of
ice were placed in front of electric fans to pro-
vide some relief. This introduction of added
moisture into the air possibly prevented many
disastrous explosions.

Should resuscitation of the newborn become
necessary7, this was accomplished by plunging
him alternately into tubs of warm and cold
w7ater. At this time there was disagreement
about the use of the umbilical binder, and
various means of identification of the newborn
were also debated. After delivery, the baby was
placed in a Gatch bed, if available, with hot
water bottles, or in the more modem hospitals,
electric heating pads. The more fortunate of

the premature babies had access to a Hess
incubator with thermostatically controlled hot
water jacket.

The picture below show's a modem nursery
of the same period.

Betty Newsom

The Waring Historical Library

ACKNOWLEDGEMENTS

Cover Picture: Courtesy Sloane Hospital for Women,
Columbia Medical Center, NY, NY.

Inside Picture: Courtesy Chicago Lying-In Hospital,
University of Chicago Hospital, Chicago, IL.

August 1989

393

IT’S 12 NOON.
TIME FOR ANOTHER
LIFE OR DEATH
DECISION.

Choosing between the blue plate special and the pot luck surprise could be the most im-
portant decision you make all day. Because if you make a habit of picking high-cholesterol
foods, you could be building up the level of cholesterol in your blood and increasing your
risk of heart attack. And your risk of death. Remem- ^
ber that the next time you browse through a menu. And AmeriCCin Heort

place your order as though your life depended on it. Association

WE'RE FIGHTING FOR
\OUR LIFE

This space provided as a public service.

Attxuwy Page

AMAA CONVENTION

The American Medical Association Auxiliary Annual Convention was held June 18-21, 1989, at
the Drake Hotel in Chicago. Those attending from the SCMA Auxiliary were Robin Meehan (Mrs.
William), President; Betsy Terry (Mrs. Lewis N.), President-elect; Virginia Johnson (Mrs. C.
Birnie), Vice-President; Maggie Bowles (Mrs. James T.), Recording Secretary; Laurie Schwarz (Mrs.
Eugene), Health Projects Chairman; Linda Galphin (Mrs. Robert), AMA-ERF Chairman; and
Rosemary Cook (Mrs. David A.), Legislation Chairman.

The opening session was highlighted by the colorful ceremony and Presentation of Presidents.
The meetings which followed were informative and interesting as we learned about national
programs and state and county projects. A very proud moment came when our SCMA Auxiliary
received three awards for our efforts during 1 988-1989. We received two membership awards — one
for increased membership and the other for increased PM/MS membership! We also received an
award for an 83 percent increase in AMA-ERF monies raised.

The Keynote Address at the opening meeting was given by the Honorable Lynn M. Martin,
member of the House of Representatives (R- 1 6th District, Illinois). Part of her address was aimed at
the importance of medical families becoming more involved in politics.

One of the most important statements Congresswoman Martin made is that not one physician
serves in Congress. However, she readily admitted that serving in Congress is a career — generally 1 0
to 20 years of service. Not many physicians can do that, but why aren’t more spouses going to
Congress? It is a big mistake not to. We have the ability, the organizational skills, the experience and
background. Most women tend to denigrate their abilities in the home, in the volunteer area and in
work which is often part time because they are raising children, so they say, “I am just doing this.”
Forty-seven percent of Auxiliary members work in their physician spouses’ offices and I bet 46
percent say, “I just work in this office.” You make it hum. You are part of what we need —
“humanistic health care.”

Representative Martin directed us to talk to our “sisters,” Republican or Democrat. In 1960, 20
women served in Congress out of 435 members. Today only 27 women serve. It is a dreadful
mistake that more women do not serve. Congress needs the strength and variation that would come
if we served. There are only two female Governors out of 50. We are all partners. We need
cooperation. Sexism and racism are “stupid, immoral and economically indefensible.”

It is time to make choices in the area of health care. We need to be there. The changes may not be
good for us or for America. We need to work together to be sure the changes are right. Represen-
tative Martin challenged us to learn and to be involved and “to remember we have a new President,
new Senate and new House. They have in their hands the chance to make America worse or better
and with God’s help and with support of people like you let’s hope it is better.”

Betsy Terry (Mrs. Lewis N.)

President-elect

August 1989

395

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C&S Bank 356

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G Geisler Group 362

Intrav 370

Eli Lilly & Company 352

The Mahaffey Agency 396

Medical Protective Company 385

Medical Software Management, Inc Cover 2

Merck Sharp & Dohme Cover 3, Cover 4

National Emergency Services 367

Pain Therapy Centers 351

Ridgeview Institute 355

Roche Laboratories 369

U.S. Air Force 362

U.S. Army Reserve 368

U.S. Navy 386

Winchester Surgical Supply Company 378

396

The Journal of the South Carolina Medical Association

^ Journal W

' OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

VOLUME 85

SEPTEMBER 1989

NUMBER 9

INDICATIONS FOR TONSILLECTOMY
AND ADENOIDECTOMY

RICHARD M. CARTER, M.D.*

J. CAPERS HIOTT, M.D.**

Tonsillectomy and/or adenoidectomy is one
of the most common operations performed in
the United States with about 800,000 cases per
year being reported in the mid-seventies. Med-
ical attitudes on the necessity for surgery have
varied from routine removal in the pre-antibi-
otic era to no removal in the early seventies, to
a more rational approach for selected cases in
the eighties.

Tonsils and adenoids are lymphoid struc-
tures with overlying epithelium which invagi-
nates to form crypts. The palatine tonsils lie on
the lateral wall of the oropharynx, and the
adenoids are in the nasopharynx. These organs
are part of the immune system and may be
involved in childhood and adult infections.
The most common microorganism recovered
from a tonsillar infection is beta streptococcus.

The symptoms of acute infection are sore
throat, fever, malaise and, at times, the gutteral
or “hot potato” voice, while the findings con-
sist of large red tonsils with exudate, tender
cervical nodes and foul breath. Noisy breath-
ing may be noted in children.

In the pre-antibiotic era, the complications
of suppurative tonsil and adenoid infections,
such as rheumatic fever and glomerulonephri-
tis, were so severe that tonsillectomy and ade-
noidectomy were recommended as a public

* 1015 Spring Street, Greenwood, S. C. 29646.

** 6 Barnett Street, Sumter, S. C. 29150.

health measure. With the advent of antibiotics
complications were reduced, routine removal
was no longer justified, and surgical treatment
was discouraged by many physicians. In 1984,
Paradise and Bluestone reported a study which
proved the effectiveness of tonsillectomy for
recurrent tonsillitis.

The most common indication for tonsillec-
tomy is recurrent tonsillitis in spite of adequate
medical therapy. Four or more episodes of
tonsillitis per year is an indication for surgery
but any patient with chronic or persistent in-
fection who has substantial loss of time from
school or work should be considered a candi-
date for surgery.

Upper airway obstruction due to tonsil or
adenoid hypertrophy may result in pulmonary
hypertension and cor pulmonale, and is a defi-
nite indication for surgical treatment. Noctur-
nal airway obstruction can be critical in a sickle
cell patient. Sleep apnea and blood gas abnor-
malities can be documented in the laboratory.
A history of nocturnal apnea and loud snoring
can be obtained. Stories such as “I have to prop
him on a pillow” or, “I have to roll him over so
he can catch his breath” are common in ENT
offices. A tape recording of respiratory noises
during sleep offers additional evidence of im-
pediment. Sleep studies are not routinely done
when the history and physical examination are
clearly diagnostic. Adenoidectomy or T&A
gives excellent results in these patients.

September 1989

403

TONSILLECTOMY

Blockage from enlarged tonsils and adenoids
may produce several less dramatic problems in
children such as failure to thrive, obligate
mouth breathing, eating or swallowing disor-
ders, tongue thrust syndrome and speech
deficiencies.

Peritonsillar abscess, which seems to be
more common in adults now than it has been
in years past, is an indication for tonsillec-
tomy. Early cases may be aborted with intra-
venous antibiotics such as penicillin or
cephalosporins. In many cases, “ripe” ab-
scesses are opened and drained, or aspirated
through a large bore needle (#16), in the office
or in the emergency room setting on cooper-
ative patients. Some patients, however, do not
cooperate because of apprehension or trismus.
A “hot” tonsillectomy or emergency tonsillec-
tomy with incision and drainage of the abscess
is cost efficient, and with skilled anesthesia and
meticulous surgical technique the morbidity
and mortality should be no different from rou-
tine tonsillectomy. Peritonsillar abscess can be
a lethal illness if untreated as has been wit-
nessed by one of the authors. George Wash-
ington reportedly died from this disease.

Suspected malignancy of the tonsil or ade-
noid is an indication for excision for diagnostic
purposes. Adenoidectomy as an independent
procedure is done for two main indications:

1. Recurrent otitis media or chronic serous
otitis media, particularly if myringot-
omies and indwelling tubes have failed.
In about half the children age two or
older, adenoidectomy has helped.

2. Hypertrophic adenoids which obstruct
the posterior choana and cause mouth
breathing, snoring, purulent or mucoid
rhinitis and sometimes sinusitis and
otitis media. The diagnosis may be con-
firmed with a lateral skull radiograph or
fiberoptic nasopharyngoscopy.

Pre-operative care includes a history and
physical examination within six weeks of sur-
gery, recording any tendency toward bleeding
or bruising in the patient or family. Systemic
disease is noted and appropriate consultation
obtained if needed. Indications for surgery are

documented. Every patient is examined for
sub-mucous cleft palate. Second surgical opin-
ions, when desired by the patient or the in-
surer, should be done by a Board Certified
Otolaryngologist. Appropriate hematological
and roentgen measures are carried out at the
discretion of the physician.

Tonsil and adenoid surgery is currently be-
ing performed in both inpatient and outpatient
surgical settings. Post-operative care requires
recovery room observation. “Observation
should be continued until the physician con-
siders the patient adequately recovered from
surgery and safe to be discharged. Occasionally
this may require several days in the hospital.
No standard fixed period of observation is safe
for all patients. Intensive care may be needed
for selected cases.”4 Prior to discharge the pa-
tient should be alert, have a good airway, no
evidence of bleeding and should be taking ade-
quate fluids by mouth to maintain good hydra-
tion. Nausea, vomiting and pain should be
under control.

Aspirin and other non-steroidal anti-inflam-
matory drugs should be avoided post-oper-
atively since they alter the blood clotting
mechanism.

Tonsil and adenoid surgery has been per-
formed with varying intensity and indications
for many years. Excellent benefits can be ob-
tained in properly selected and carefully man-
aged patients. □

REFERENCES

1 . Maw, A. R.: Tonsillectomy Today, Archives of Disease
in Adulthood, 1986, Vol. 61, p. 421-423.

2. Gates, A. G. and Folbre, T. W.: Indications for Ade-
notonsillectomy, Archives of Otolaryngology — Head
and Neck Surgery, 1986, Vol. 112, p. 501-502.

3. Paradise, J. L.; Bluestone, C. C., Bachman, R. Z., et al.,
Efficacy of tonsillectomy for recurrent throat infection
in severely affected children: Results of parallel ran-
domized and nonrandomized clinical trials. New
England Journal of Medicine, 1984, 310: 674-683.

4. Pre-operative and Post-operative Guidelines for Ton-
sillectomy and Adenoidectomy in Children and Adults,
The Bulletin of the American Academy Of Otolaryn-
gology— Head and Neck Surgery.

5. Kornblut, A. D., M.D., F.A.C.S.: A Traditional Ap-
proach to Surgery of the Tonsils and Adenoids,
Otolaryngologic Clinics: The Tonsils and Adenoids,
May 1987, 20:2, p. 349-361.

404

The Journal of the South Carolina Medical Association

CURRENT TECHNIQUES IN EVALUATION
OF A NECK MASS

ROBERT C. JORDAN, M.D.*

AUGUSTUS J. GOFORTH, III, M.D.**

The patient presenting with a lump in the
neck is a unique challenge to the clinician. To
ensure the best possible care of the patient, the
temptation to schedule an open biopsy as the
initial step in evaluation of the mass must be
avoided and an orderly diagnostic determina-
tion undertaken.

Along with past and family history the perti-
nent data includes the age and sex of the pa-
tient, exposure to known carcinogens, the time
course of the development of the mass, fluctua-
tion in size, history of recent febrile illness and
exposure to a chronic or acute illness. A well-
defined history will direct the physical exam-
ination and the remaining procedures.

A thorough physical examination of the
head and neck is essential, but not limited to
this region, since metastatic malignancies from
lung, kidney, ovary, prostate, and other areas
beneath the diaphragm are well documented. 1
Similarly, a low, lateral neck mass has been
noted as the presenting sign of metastatic thy-
roid carcinoma.2

Examination of the ear, nose, pharynx, and
larynx as well as palpation of the mass, noting
its consistency and mobility, is first performed,
followed by examination of the remainder of
the neck and a search for less obvious masses.
Indirect mirror examination of the naso-
pharynx, larynx, hypopharynx, and base of
tongue, along with direct observation of the
tonsils, nose and sinus ostia can be supple-
mented with outpatient rigid and flexible
fiberoptic instrumentation of the upper aero-
digestive tract. A preponderance of primary
carcinomas, origins of cervical cysts and si-
nuses, causes of salivary gland enlargement
and upper aerodigestive tract infections con-
tributing to a neck mass are revealed by this
method.

* Suite 101, 175 Charlois Blvd., Winston-Salem, N. C.
27106.

**317 St. Francis Dr., Suite 170, Greenville, S. C. 29601.

The logical evaluation of the neck mass
should not consist of a myriad of tests without
a rational sequential approach. If an obvious
origin is found by head, neck and general phys-
ical examinations, the primary lesion is dealt
with in conjunction with the neck mass. Fine
needle aspiration cytology of the mass may be
helpful in better defining the relationship with
the primary lesion, and in squamous cell car-
cinoma has proved to be highly specific and
sensitive in the diagnosis of metastatic disease
to the cervical lymph nodes.3

When no obvious primary lesion is identi-
fied, a more extensive workup is pursued, in-
cluding at a minimum roentgenograms of the
chest and sinuses, complete blood count and
various other blood tests as indicated, such as
monospot, ASO titers, serum calcium and thy-
roid profile.4 Computed tomography (CT) of
the neck may be highly useful in diagnosing
neck disease, however it is much more accu-
rate in ferreting out metastatis in a patient with
a known primary head and neck cancer.5 Mag-
netic Resonance Imaging (MRI) is a similar
aid, and CT or MRI is employed to further
assess the extent of neck disease in a patient
with a known primary lesion. CT or MRI is
useful in the detection of small nodes, particu-
larly in individuals with short, fat or muscular
necks (Fig. I). These studies are essential for
the detection of parapharyngeal metastases
and can frequently determine tumor encroach-
ment on the carotid system, obviating ar-
teriography in many advanced cancer cases.

With an unknown primary source, the sen-
sitivity and specificity of needle aspiration
cytology in diagnosing neck disease has been
high.6’ 7 The practice is generally safe and well
tolerated by patients on an outpatient basis.
The fine needle size mitigates against tumor
spread in the case of malignancy. When the
aspirate is benign or nonconclusive, close fol-
lowup is continued if cancer remains under
suspicion.

September 1989

405

NECK MASS EVALUATION

FIGURE 1

In the setting of metastatic head and neck
carcinoma, biopsy of the mass prior to identifi-
cation and treatment of the head and neck
primary neoplasm leads to increased mor-
bidity and mortality by expanding the rate of
local recurrence, distant metastasis, and
greater exposure to wound complications after
subsequent definitive neck dissection.8 To
avoid such problems, an operative search for
the primary tumor is undertaken prior to the
biopsy. The procedure is commonly per-
formed by an otolaryngologist and comprises
upper aerodigestive tract endoscopy and blind
biopsies of high risk areas (nasopharynx, ton-
sils, base of tongue, pyriform sinuses) in the
event that no primary is noted.4 Definitive
treatment of the metastatic lymph nodes and
the primary, if identified, is then initiated.

Provided a primary lesion is not recognized
and the nature of the cervical mass remains
unknown despite a thorough workup, an open
biopsy is planned. The incision is devised so
that a radical neck dissection may be com-
pleted in case carcinoma is documented by
frozen section study. In the presence of a su-
praclavicular enlargement, further workup en-
tails intravenous pyelogram, upper gastroin-
testional series, barium enema and/or colon-

oscopy,4 pursuing a primary lesion.

If precise substantiation of carcinoma begin-
ning in the cervical lymph nodes is lacking,
then failure to initially locate the principal
tumor requires constant reevaluation of the
patient’s status.

CONCLUSION

The evaluation of a lump in the neck follows
a logical sequence dictated by location of the
mass, makeup of the patient, duration of
symptoms, and level of suspicion of malig-
nancy. Initial open biopsy before completion
of a diagnostic workup can lead to complica-
tions and increased morbidity and mortality.
Thin needle aspiration cytology and upper
aerodigestive track endoscopy with directed or
blind biopsy are valuable tools in the evalua-
tion process. An open biopsy in the case where
thorough workup fails to yield a diagnosis
should be performed by a surgeon prepared to
complete a concomitant radical neck dissection
if the histologic findings reveal carcinoma. □

REFERENCES

1. Lore JM(ed): Atlas of Head and Neck Surgery. W.B.
Saunders, Philadelphia, 1988, page 649.

2. Maceri DR, Babyak J, Ossakow, SJ: Lateral Neck Mass.
Archives Otolaryngol Head Neck Surg-Vol 112, Jan.
1986, page 47-49.

3. Feldman PS, Kaplan KJ, Johns ME, Cantrell RW: Fine
Needle Aspiration in Squamous Cell Carcinoma of the
Head and Neck. Arch Otolaryngol- Vol 109, Nov 1983,
pp 735-742.

4. Jaques DA: Management of Metastatic Nodes in the
Neck from an Unknown Primary. Paparella Shumrick,
Otolaryngology, Second Edition, Vol III, pp 2998-3003.

5. Friedman M, Shelton VK, Mafee M, Bellity P, Gry-
bauskas V, Skolnik E: Metastatic Neck Disease. Arch
Otolaryngol- Vol 110, July 1984, pp. 443-447.

6. Small LA, Young JA, Oates J, Proops DW, Johnson AP:
Fine Needle Aspiration Cytology in the Management
ENT of Patients. Journal of Laryngol and Otol-Vol 102,
Oct 1988, pp. 909-913.

7. Raju G, Kakar, PK, Das DK, Dhingra PL, Bhambhani
S: Role of Fine Needle Aspiration Biopsy in Head and
Neck Tumours. Journal of Laryngol and Otol-Vol 102,
Mar 1988, pp. 248-251.

8. McGuirt WF, McCabe BF: Significance of Node Biopsy
Before Definitive Treatment of Cervical Metastatic
Carcinoma. The Laryngoscope 88:1978.

406

The Journal of the South Carolina Medical Association

MULTIMODALITY TREATMENT OF
ADVANCED HEAD AND NECK CARCINOMA

L. S. CARLSON, M.D.

R. STUART, M.D.

J. D. OSGUTHORPE, M.D.

Nearly a third of patients with squamous cell
carcinoma of the head and neck present with
advanced lesions.1 These lesions are charac-
terized by large bulky primary tumors with or
without extensive nodal metastasis which may
themselves be large (Fig. 1). Often these tu-
mors are unresectable at time of presentation.
Treatment with surgery or radiation therapy
results in low survival rates, with most patients
dying of local or regional recurrence of tumor.
In this paper, we will discuss recent develop-
ments in combined modality treatments which
are designed to improve this dismal situation.

Several factors contribute to the poor prog-
nosis in these patients. Primary tumors that
have eroded bone or metastasized to the neck
require complex and often massive resections,
when they are resectable at all. Large solitary or
multiple lymph node metastases predict a
higher likelihood of recurrence. In addition,
patient factors are important: these patients
often have unhealthy lifestyles, abusing to-
bacco and/or alcohol; they may be malnour-
ished; many have neglected oral hygiene; and,
frequently, they have denied their symptoms
and delayed medical care. Often such patients
are poorly motivated to undergo aggressive
and complicated treatment protocols.

Treatment of advanced head and neck can-
cer with surgery and/or radiation therapy re-
sults in survival rates of approximately
10-20%.2 Radiation therapy has been used
both preoperatively and postoperatively. Pre-
operative radiation has the advantage of de-
creasing tumor size and making resection
possible in some cases. It can also sterilize the

* From the Department of Radiation Oncology (Dr. Carl-
son), the Division of Hematology/Oncology (Dr. Stuart),
and the Department of Otolaryngology and Commu-
nicative Sciences (Dr. Osguthorpe), Medical University
of South Carolina, 171 Ashley Avenue, Charleston, S. C.
29425-2242.

tissue surrounding bulky tumor masses, so that
margins of resection will be free of tumor.
However, relatively low doses of 45-50 Gy
must be used so as not to make the surgery
difficult. Even so, postoperative complica-
tions, such as delayed wound healing, are
increased.

Postoperative rather than preoperative radi-
ation therapy has been given more often in
recent years. Fields can be tailored to give
higher doses in the areas of greater tumor in-
volvement. However, all tissue in the resected
area has been disturbed, and the lymphatic
channels may shunt outside of their normal
pathways. Initial treatment fields are generally
quite large.

FIGURE 1. Patient with advanced neck node metastases.

September 1989

409

ADVANCED CARCINOMA

In recent years, several investigators have
used chemotherapy for advanced head and
neck tumors. Dramatic responses with single
agents and multiple agents have been seen,
particularly with drug combinations which in-
clude cisplatinum, the most active single agent
against head and neck cancer.3 This drug has
also been found to be synergistic with radiation
therapy. Other drugs showing synergy when
combined together with radiation therapy,
though not with undue toxicity, include 5-fluo-
rouracil (5-FU), and etoposide (VP-16).4’ 5

Several recent studies have been published,
describing the outcome of patients treated with
combinations of chemotherapy, radiation
therapy and surgery. There is much contro-
versy in this recent literature, for some studies
have shown increased survival with the multi-
modality treatment, while other studies have
shown no benefit, or even lower survival.6 Sev-
eral factors make an analysis of these studies
quite difficult. First of all, cancer in the head
and neck area can arise in many sites, with each
site having its own propensity for spread to
lymph nodes in various pathways. Thus, the
prognosis is inherently different for tumors of
the same stage that have arisen in different
sites.

In addition, the staging system that is uni-
versally accepted by the American Joint Com-
mittee for Cancer is quite well defined and
useful when speaking of each tumor by its
TNM classification.7 However, when discuss-
ing stage, early primary tumors (TbT2) with
limited nodal spread (N,) are included in the
same stage category (Stage III) as late tumors
(T3) with limited nodal spread (Fig. 2). Since
many of the recent treatment studies include
Stage III and/or IV tumors, those with higher
proportions of these early lesions might be
expected to do better. Often, tumors are not
specified in these studies beyond the general
stage grouping.

Moreover, there has been a marked lack of
uniformity in the design of the recent trials.
Multiple combinations of chemotherapeutic
agents are described, and often they are given
in different doses. Some studies do not specify
the radiation therapy dose or the fractionation
schedule which was used. The sequence of de-
livering chemotherapy, irradiation and surgery
is quite variable in these studies, although

Ti T2 T3 T4

FIGURE 2. American Joint Committee Cancer Staging
Grouping.7

many have given the chemotherapy first, fol-
lowed by surgery and/or radiation therapy.
Table 1 illustrates various strategies that have
been used.

All of these studies have been reported with
relatively short follow-up. And few, if any,
report the number of patients which have been
salvaged with surgery or radiation therapy
when combined modality treatment has failed.
This is particularly important, because surgical
salvage following chemotherapy or radiation
therapy can be successful.

Surveying recent literature leads one to the
inevitable conclusion that there is a need for a
national cooperative trial to determine the op-
timal combination of treatment for advanced
head and neck tumors. However, nonran-
domized, small pilot studies are still of benefit,
for it is from these that we determine the tox-
icity of combined modality therapy, as well as
gain some indication of efficacy. At MUSC, we
are currently using a treatment protocol for
patients with advanced head and neck car-
cinoma. This protocol uses cisplatinum, 5-FU,
and etoposide given simultaneously with pre-
operative radiation therapy.

The MUSC pilot study was devised to take
advantage of the synergistic effect of these
drugs with radiation therapy. In addition, be-
cause chemotherapy and radiation therapy are
given concomitantly, it is hoped that there will

410

The Journal of the South Carolina Medical Association

ADVANCED CARCIMONA

TABLE 1

Strategies for Treatment of Advanced Head and Neck Cancer

Initial Therapy
Surgery

Radiation Therapy

Surgery

Chemotherapy

Chemotherapy and
Radiation Therapy
(Concomitant)

Adjuvant or Completion Therapy

Radiation Therapy
Surgery

Salvage Therapy
Radiation Therapy
Surgery

Radiation Therapy
Surgery

be less likelihood of the local tumor continuing
to seed the blood stream with microme-
tastases, a theoretical explanation which has
been given to account for lack of improvement
in survival in studies which use sequential
chemotherapy and radiation therapy. We also
feel that we are using an optimum drug com-
bination. combining three agents which have
all been shown to be synergistic and effective
against these tumors. Pre-operative radiation
therapy (50 Gy) is begun simultaneously with
chemotherapy, so as not to postpone the initia-
tion of local regional treatment. Surgery to
remove all tissue which was initially affected is
performed to insure removal of residual mi-
croscopic nests of disease. When surgery is not
possible, radiation therapy is continued to
higher, definitive doses.

Results in our pilot study are very early ( 1 5
patients to date), but to date the toxicity does
not appear to be prohibitive, and we have been
impressed with the response of some of our
patients. It is hoped that once the pilot study is
completed and analyzed, we will be able to

embark on a multiinstitutional randomized
trial of combined modality therapy for ad-
vanced head and neck tumors. □

REFERENCES

1. Million RR. Cassisi NG. Management of Head and
Neck Cancer. A Multidisciplinary Approach. Phila-
delphia. JB Lippincott, 1984.

2. delRegato, JA, Spjut HJ. Cox JD. eds. Ackerman and
delRegato’s Cancer. Diagnosis. Treatment, and Prog-
nosis, Ed. 6. St. Louis. C.V. Mosby Co., 1985.

3. Wittes R. Heller K. Randolph V, et al. Cisdichlorodia-
mineplatinum (II Phased chemotherapy as initial treat-
ment of advanced head and neck cancer. Cancer Treat
Rep 63:1533-1538, 1979.

4. Weaver A Hemming S. Kish J. et al. Cisplatinum and
5-fluorouracil as induction therapy for advanced head
and neck cancer. .Am J Surg 144:445, 1982.

5. O’Dyer PJ. Leyland-Jones B. .Alonso MT. Marconi S,
Wittes RE. Etoposide (VP- 16-2 13): Current status of an
active anticancer drug. New England J Med 1985;
312:692-700.

6. Tannock IF. Browman G. Lack of evidence for a role of
chemotherapy in the routine management of locally
advanced head and neck cancer. J Clin Oncol. 4 (7):
1121-1126, 1986.

7. American Joint Committee on Cancer: Manual for
Staging of Cancer. 2nd ed.. Philadelphia. JB Lippincott.
1983.

September 1989

411

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412

The Journal of the South Carolina Medical Association

INHALANT ALLERGIES: SKIN VERSUS
IN VITRO TESTING

GIEN HOANG, M.D.*

ROBERT G. MAHON, JR., M.D.**

Inhalant allergic diseases affecting the ears,
nose and throat comprise a large segment of
the general otolaryngologist’s practice and is a
legitimate concern of his patient care. Skin
endpoint titration (SET), an in vivo test, and
radioallergosorbent test (RAST), an in vitro
test, are two of the diagnostic techniques avail-
able and commonly practiced by otolaryn-
gologists— head and neck surgeons. As report-
ed by the Council on Scientific Affairs of the
American Medical Association (JAMA; 1987,
258:1506), before immunotherapy “patients
should be shown to have an IgE-mediated reac-
tion to the allergen by skin testing or by dem-
onstrating serum IgE antibodies by radio-
allergosorbant test or other in vitro tech-
niques.”

SKIN ENDPOINT TITRATION

Skin Endpoint Titration (SET) makes use of
a set of solutions with the antigen concentra-
tion decreased by a factor of five in each vehi-
cle in order to estimate the degree to which a
patient is sensitive to any particular allergen
and, hopefully, to allow an appropriately po-
tent initial starting dose for immunotherapy.
To prepare the test set, six vials each with 4 ml.
of diluent is prepared. One ml. of antigen con-
centrate (usually 1:20 wt/vol) is added to the
first vial to make Solution #1 1:100 solution,
and one ml. of # 1 is then mixed with the next
vial to make a 1:500 reduction (#2). This pro-
gression is continued to Solution #6,
1:312,500, which is the starting dosage, since
no significant systemic reaction is known to
occur at this concentration. Many physicians
prefer to begin with a screening panel com-
monly containing 1-2 grasses, weeds and tree

* Department of Otolaryngology and Communicative
Sciences, Medical University of South Carolina,
Charleston, S. C. 29425-2242.

** 701 Arlington Avenue, Greenville, S. C. 29601.

pollens prevalent in the area, extracts of house
dust, mites, 2 molds (Altemaria and Hormo-
dendrum), and dog and cat danders if indi-
cated by exposure.

Placement of the test wheal is critical. It
must be intradermal and exactly 4 mm. When
read in 10 minutes a negative response is no
reaction, disappearance of wheal or an increase
in size to no more than 5 mm. With this survey
Solutions #5, #4, and #3 are placed simul-
taneously about 2 to 3 cm. apart. After 10
minutes the ideal positive in an allergic indi-
vidual would be for the wheals to increase to 5,
7, 9 or 7, 9, 11 for Solutions 5, 4 and 3 respec-
tively, the end point being 7 mm. which is 2
mm. larger than the negative 5 mm. swelling.
In 70 percent, there is this increase, but in the
other 30 percent, aberrant or atypical flares
require reassessment.

RAST

The radioallergosorbent test was developed
in the early 1970s following discovery of the
exact nature of IgE in 1967, and detects specific
IgE antibodies in the serum. Since the initial
commercially available RAST addition, sev-
eral changes have improved its sensitivity, one
of which is the modified RAST test (MRT)
devised by Nalebuff and Fagal to approximate
the scoring of the Rast systems to the results of
SET. About 85 percent of the RAST tests prev-
alent in this country rely on the modified
RAST (Table I).

Modified RAST is expensive (from 25 to 50
percent more than skin endpoint titration). To
circumvent that drawback, a RAST mini-
screen is available typically containing six ma-
jor inhalant allergens, and it is claimed that less
than two percent of atopic patients have a
negative reaction to such a panel. If the initial
screen is positive, additional tests are per-
formed by an in vivo or in vitro method, with
the assurance that the subject has inhalant al-
lergies and such testing (and cost) is warranted.

September 1989

415

INHALANT ALLERGIES

TABLE I

Modified RAST Scoring System

Class

Count*

Interpretation

250-500

Negative

1/0

501-750

Equivocal

751-1,600

Usually positive

1,601-3,600

Positive with

3,601-8,000

increasing levels

8,001-18,000

of specific IgE

18,001-40,000

* Counts obtained when time control of 25 units is run at
25,000 counts.

From “Introduction To Otolaryngic Allergy,” Gary D.
Becker, M.D., Editor. AAO-HNS Foundation 1986.

COMPARISON BETWEEN SAT
AND RAST

The advantages of skin endpoint titration
are that it requires less expensive equipment,
offers expanded possible antigens, and is more
sensitive. In other respects, it may give addi-
tional false positives, and the individual has to
be present — thus missing work, with the dis-
comfort of multiple sticking. There is slight
bleeding at times, danger of constitutional re-

actions, and the results are affected by certain
medications such as antihistamines.

The RAST tests have fewer antigens com-
mercially available and are less sensitive and
more expensive than skin tests, but offer con-
venience, especially with working individuals,
children and those with skin problems. There
is also no danger of constitutional reactions or
interference by medication.

Skin endpoint titration and RAST tests are
no more than tools in the evaluation of the
allergic patient which need to be correlated
with other findings in the physical examina-
tion and history. If immunotherapy is indi-
cated, the antigen dose should be serially
increased to the maximum tolerated or symp-
tom-relieving level, whichever comes first. □

REFERENCES

Further information concerning the previously dis-
cussed subject can be found in the following publications:

1. Introduction to Otolaryngic Allergy. G.D. Becker Ed.
AAO-HNS Foundation, 1986.

2. Endpoint Titration and Immunotherapy. H.C. King,
Symposium on Immunology and Allergy. 1 8( 1 ):703-7 1 7;
1985.

3. Efficacy of a Screening Radioallergosorbent Test. W.P.
King, Arch. Oto. 1 08:78 1 -786; 1 982.

4. RAST In Clinical Allergy. R.G. Fadal and D.J.
Nalebuff. Yearbook Medical Publishers, Chicago, 111.
1981.

416

The Journal of the South Carolina Medical Association

ENDOSCOPIC TECHNIQUE FOR
SINUS SURGERY

JUAN A. BROWN, M.D.*

L. RONALD HURST, M.D.**

New technical development, particularly in
engineering and optics, continues to change
the concept of modern medicine and surgery.
Otolaryngology is not the last of those which
have made use of new equipment for diagnosis
and therapy, derived specifically through the
combined modalities of nasal endoscopy and
high resolution, computerized tomography of
the sinus cavities. Despite the fact that the
basic surgical principle is to remove all
obstructions, visualization or surgical ap-
proach to the natural openings of the sinuses
has been deficient. Diagnostic tools to evaluate
sinus disease in the past have been limited and
consisted primarily of anterior rhinoscopy in-
cluding anterior microscopic visualization and
conventional roentgenograms.

Messerklinger1 published his first works in
English in 1978, documenting the findings and
results of endoscopic surgery. Utilizing the
concept of mucocilia clearance of secretions
from the sinuses, he proved that localized
obstruction occurred whenever two mucosal
layers contacted each other. This persistent
mucosal contact is secondary to hyperplasia
following infection, allergy or anatomic mal-
formations, either developmental or traumatic
(Table 1). Relatively small areas of infection
and obstruction may be the cause of persistent
sinus symptoms, usually centered in the mid-
dle meatus, infundibulum and anterior and
middle ethmoids. This area has been termed
the osteomeatal unit and in the immediate area
are the meninges, orbit and several vessels
including the carotid artery. Access is ex-
tremely restricted, and the surgical approach in
the past has been difficult and complicated.

The symptomatology consistent with chron-
ic sinus involvement comprises purulent post-
nasal drainage with halitosis, headaches, fever,

* 1303 McLees Road, Anderson, S. C. 29621.

** 397 Serpentine Road, Spartanburg, S. C. 29303.

TABLE 1

Etiology of Chronic Obstruction of the Osteomeatal Unit

A. Nasal polyps

1. Allergic

2. Infection

B. Turbinate engorgement

1. Allergic

2. Infection

C. Turbinate enlargement

1. Congenital

2. Allergies

D. Deformity of uncinate process; ethmoid bulla

1. Congenital

2. Traumatic

E. Deviated nasal septum

1. Congenital

2. Traumatic

F. Fractures, (Leforte, nasal)

1. Acute

2. Chronic

periorbital pain and glabella pressure, as well
as congestion of the nasal vestibule. Pulmon-
ary problems of asthma, bronchitis, recurring
pneumonia and chronic cough are frequently
evident (Table 2). The diagnosis of chronic
sinusitis is accomplished by obtaining a signifi-
cant history of recurring sinus complaints. The
physical examination reveals an obstructive
phenomenon such as a deviated septum,
polyps, turbinate engorgement, purulent
drainage, though it can occasionally be com-
pletely normal. Conventional roentgenograms
may be reported as chronic sinusitis with thick-
ened mucosa, cysts, polyps, pansinusitis or
normal, and seldom fully delineate the eth-
moid sinuses or identify the blockage within
the osteomeatal unit.

In the face of negative clinical and roentgen
findings, if a patient’s history is compatible
with sinusitis, the new diagnostic tools of
which endoscopic appraisal of the patient in
the office and coronal CT views of the sinuses
with particular attention to the osteomeatal
units are available.2’ 3 Coronal positioning of
the patient for the CT provides an exact

September 1989

417

SINUS ENDOSCOPY

TABLE 2

Symptoms of Chronic Sinuses Disease

A. Congestion/obstruction

B. Secretion, halitosis

C. Fullness/pressure — mild to severe pain

D. Headache — temporal, frontal

E. Dental pain

F. Chronic pulmonary conditions

1. Chronic cough

2. Bronchitis

3. Asthma

4. Recurrent pneumonia

method of delineating an obstructive process
of the osteomeatal unit,4 which is refined by
direct endoscopic visualization with the pa-
tient in the sitting position under topical anes-
thesia. Neither of these techniques is invasive
or painful, and each is performed on an outpa-
tient basis.

Endoscopic sinus surgery is employed to re-
move the obstruction within the osteomeatal
unit when medical therapy fails to eliminate
the symptoms. Severe diseased sinus mucosa
reverts to its normal state once aeration and
mucosal clearance have been restored. The au-
thors have operated under general anesthesia
in 225 cases with the patients leaving the out-
patient facility in two to three hours after sur-
gery and returning to work three to seven days
later. Nasal packing is not generally required.
Local anesthesia with IV adjunctive therapy
may be administered depending on the pa-
tient’s and surgeon’s preferences. Classical ma-
jor sinus methods such as Caldwell-Luc, osteo-
plastic frontal sinus operations and total
ethmoidectomies are now less frequently
necessary.

Endoscopic surgery permits the resolution of
multiple sinus cavity disease including bilat-
eral involvement as one procedure. Post-oper-
atively, the patient has little discomfort and
disability without any sensory loss or cosmetic
changes, i.e., bruising or periorbital edema.
The complications of endoscopic or any other
sinus surgery are directly related to the specific
anatomic area and can be life threatening,5 as
denoted by orbital emphysema, hematoma,

TABLE 3

Complications of Endoscopic Sinus Surgery

A. Major

1. Hemorrhage

2. CFS Leak

3. Blindness

4. Meningitis

B. Minor

1. Orbital hematoma

2. Orbital emphysema

3. Nasolacrimal duct stenosis

nasolacrimal injuries, CFS leak, meningitis
and blindness (Table 3).

In summary, chronic sinus disease may be a
meaningful factor in the lifestyle of patients. It
can interfere with physical health as well as
their occupations and emotional outlook.
Medical therapy, in conjunction with allergic
evaluations, remains the primary mode of
treatment. The new diagnostic techniques help
further in assessing sinus disease, and endo-
scopic functional surgery promises calculable
benefits with less morbidity than conventional
open surgical techniques, in accord with the
trend toward minimal invasive surgery. Three
complementary developments have contrib-
uted to this new approach:

(1) high resolution CT scans in the coronal
positions,

(2) advanced endoscopic instruments im-
proving the visualization and surgical
treatment of the osteomeatal units, and

(3) identification of the anterior ethmoid

osteomeatal unit as the underlying site
of most sinus problems. □

REFERENCES

1. Messerklinger W: Endoscopy of the Nose. Baltimore,
Urgan & Schwarzenberg, 1978.

2. Stammberger H & Wolf G. Headaches and sinus disease
the endoscopic approach. Annals of Otology, Rhi-
nology, Laryngology Supplement 134, Sept. Oct. 1988.

3. Kennedy DW et al. Functional Endoscopic Sinus Sur-
gery. Arch Otolaryngology, Vol. III. Sept. 1985.

4. Zimeich, SJ. Paranasal Sinuses: CT Imaging Require-
ments for Endoscopic Surgery. Radiology 163: 769-775,
1987.

5. Stankiewicz, JA. American Journal of Rhinology. Vol.
1. No. 1: 45-49, 1987.

418

The Journal of the South Carolina Medical Association

NEWSLETTER

SEPTEMBER 1989

MEDICARE UPDATE

Applicability of MAAC When Medicare is Secondary Pavor

The SCMA has received clarification from Blue Cross and Blue
Shield of South Carolina that nonparticipating physicians may
charge more than their MAACs when (1) a beneficiary has other
primary insurance and (2) the physician agrees to accept this
insurance as payment in full without collecting any copayment or
deductible payment from the patient.

Medicare; ICD-9-CM Coding

To assist physicians in finding an appropriate diagnosis code,
AMA will be publishing abstracted sets of the ICD diagnostic
codes based on medical specialty groupings as part of the CPT
1990 minibook series. A limited number of complete ICD manuals
has been obtained by AMA. These are available for $38.40 to AMA
members. Manuals may also be purchased from the Government
Printing Office for $43. AMA members may place VISA or
Mastercharge orders for the just-updated publication by calling
1-800-621-8335. The publication number is OP-219 ( ICD-9-CM

International Classification of Diseases. 9th Revision, Clinical
Modification, 3rd edition) . Other orders should be directed
(with prepayment in full) to AMA, OP-219, PO Box 10946, Chicago,
IL 60610-0946.

Medicare Information Booths

In a continuing effort to provide information and education to
the Medicare community, Medicare will be manning a booth at the
Anderson County, Coastal Carolina and South Carolina State Fairs
this fall. Detailed personal information concerning Medicare
procedures and inquiries regarding specific claims can be
provided to everyone who visits the booths. The schedule is as
follows:

Anderson County Fair (Anderson) :

SC State Fair (Columbia) :

Coastal Carolina Fair (Ladson) :

MEDICAID UPDATE

As part of the statewide efforts to encourage physicians to care
for Medicaid patients, the Health & Human Services Finance

September 15-23
Exhibit Building
October 12-22
Moore Building
October 26-November 4
Exhibit Building

Commission has concentrated on improving claims processing,
reimbursement rates and the audit procedures.

Ms. Carolyn Jordan, Director of Program Integrity at the Finance
Commission, has prepared an "Overview of Medicaid Postpayment
Review Process," to help physicians better understand why the
Finance Commission conducts audits, how physicians are selected
to be audited and how the audit process is conducted. Of special
interest is the fact that a large volume of Medicaid patients
does not generate an audit. For a copy of Ms. Jordan's overview,
contact Kim Fox or Joy Drennen at SCMA Headquarters.

If you have any suggestions/problems with Medicaid that your
staff has been unable to resolve with the Medicaid provider
representatives, please call Barbara Whittaker at the SCMA.

PRO UPDATE

Carolina Medical Review (CMR) wishes to clarify information
published in last month's "SCMA Newsletter" concerning the
Quality Intervention Plan (QIP) which had been reprinted from an
AMA newsletter. The QIP sets forth three levels of medical
mismanagement (HCFA terminology) which are determined based on
either no potential for significant adverse effects, potential of
significant adverse effects or significant adverse effects. Each
level is assigned a severity weight.

Each quarter, the PRO will profile the total weights accumulated
for reviews completed during that quarter for each physician or
provider. The total severity weight will determine the type of
corrective action to be considered for implementation. The PRO
must consider initiation of corrective action when any physician
or provider receives a total weighted score of three or more. In
general, interventions will be initiated based on CMR computed
HCFA severity level weights and weighted triggers for
intervention. However, the triggers for intervention can be
overridden by quality review panels. Flexibility in determining
what intervention is appropriate is paramount to prevent
potential for perception that the point system is an arbitrary
mechanism.

PHYSICIAN OWNERSHIP OF HEALTH FACILITIES TO WHICH REFERRALS ARE
MADE

Under current federal law, physicians are not explicitly
prohibited from maintaining an ownership interest in most types
of facilities to which they may make patient referrals. The only
existing federal prohibitions that explicitly bar physicians from
self -ref erring patients involve providers of home intravenous
drug therapy under the Medicare Catastrophic Coverage Act of 1988
(PL 100-360) , effective January 1, 1990, and home health agencies
in cases in which federal law prohibits physicians who own more
than five percent of the agency from certifying the plan of
treatment for home health care.

Laws exist, however, to prohibit inappropriate referrals.
Congress included in the Social Security Amendments of 1972 (PL
92-603) a provision that outlawed payments for referrals of
business payable under Medicare and Medicaid. The penalties were
a misdemeanor conviction, one year of imprisonment and a $10,000
fine. Five years later, in the Medicare/Medicaid Anti-Fraud and
Abusement Amendments of 1977 (PL 95-142) , Congress expanded the
law to cover any "remuneration" that sought to induce referrals
of patients or business under the two programs, and strengthened
the penalty to a felony conviction with up to five years in
prison and $25,000 in fines. In the Omnibus Reconciliation Act
of 1980 (PL 96-499) , Congress acknowledged the ambiguity of the
earlier statute by providing that conduct is unlawful only if it
is undertaken "knowingly and willingly."

In April, 1989, the inspector general issued a "fraud alert on
joint ventures," making clear that an investment relationship
even with no explicit tie to referrals may violate the law. This
willingness to look behind the legal structure of a venture
involving physicians to determine whether its purpose appears to
be the inducement of referrals is also reflected in the few
relevant federal appellate court cases decided in recent years.
Representative Stark's legislation proposes to further
restrict/prohibit referrals of Medicare patients. This
legislation is pending Congressional action.

SCMA ENDORSES DIAL ACCESS CONTINUING MEDICAL EDUCATION

The SCMA Board of Trustees, on the recommendation of the CME
Committee, has endorsed the Dial Access Continuing Medical
Education program of the Southern Medical Association.

Since 1978, more than 250,000 physicians have used a Southern
Medical Association-sponsored toll-free hotline to get instant
access to the latest medical information, 24 hours a day, 365
days a year. After paying a nominal subscription fee, the
physician receives a catalog containing over 800 audiotapes on
specific clinical topics catalogued by discipline and number.
The user tells the operator his or her ID number, the number of
the tape he wishes to hear, and then listens to a six- to eight-
minute lecture. If he requests it, a typed version will be sent
to him within a few weeks. The tapes are eligible for hour-
for-hour credit in category 2 of the AMA's Physician Recognition
Award and Prescribed credit of the American Academy of Family
Physicians.

For information on subscribing, contact Bruce J. Bellande, Ph.D.,
1-800-423-4992 or write the Southern Medical Association, PO Box
190088, Birmingham, AL 35219-0088.

MEDICAL LIABILITY PURCHASING GROUP. INC.

In February of this year, SC physicians were alerted that the
Medical Liability Purchasing Group, Inc. had been instructed to

discontinue the solicitation of medical liability coverage to
residents of SC until the company (The Casualty Assurance Risk
Insurance Brokerage Company) was duly qualified and the
purchasing group properly registered in this state. In June, the
Indiana Department of Insurance obtained an injunction against
the Medical Liability Purchasing Group, Inc., of Indiana. The
injunction noted that the information contained in the
solicitations in Indiana was false in several respects and
induced health care providers to purchase insurance from an off-
shore company which has not been admitted to do business in any
state.

UPCOMING CONFERENCES

The AMA is cosponsoring a series of comprehensive one-day
seminars on "Managing Medical Wastes" to guide physicians and
other healthcare professionals in implementing effective medical
waste management programs. Other cosponsors are the American
Society of Hospital Engineering and the American Society for
Healthcare Environmental Services.

The program will apprise physicians and others of requirements of
the Medical Waste Tracking Act and of the repercussions that can
result from improper waste handling.

One such program is scheduled for October 18 in Charlotte, NC.
Registration fee is $150 for AMA members. To register, call 1-
312-940-2138. For more information, call the American Hospital
Association, 1-312-280-5223 or 3365.

PUBLICATIONS AVAILABLE

Copies of the 1989 edition of CURRENT OPINIONS of AMA's Council
on Ethical and Judicial Affairs are now available. AMA members
may obtain a single complimentary copy by calling toll free 1-
800-621-8335. Single additional copies are $8 each for members
and $15 for non-members.

CAPSULES

Three distinguished South Carolinians have been honored by the SC
Chapter of the American Academy of Pediatrics. Michael D.
Jarrett, DHEC Commissioner, received the Child Advocate of the
Year Award for his contributions to the health and well-being of
South Carolina's children. The Career Achievement Award was
presented to Casper E. Wiggins, MD, for his superior
accomplishments in the field of medicine. W. John Langley, MD,
received the President's Award for his outstanding service to the
chapter, its activities and the children of the state.

EXTERNAL RHINOPLASTY

WILLIAM R. LOMAX, M.D.*
KENNETH A. BROWN, M.D.**

The nose is a rather prominent and visible
anatomic structure; deformities of the nose
cannot be hidden by clothing, makeup or hair
styling. This makes rhinoplasty the most chal-
lenging of all facial surgical procedures. The
goal of rhinoplasty is to obtain a pleasing, natu-
ral, functioning esthetic facial unit that does
not have an obvious “nose job” look.

Good surgical results are based on a thor-
ough knowledge of anatomy, good surgical
technique and adequate exposure. In this re-
gard, rhinoplasty is no different from any other
surgical procedure, and in many respects, the
need for exposure is greater, as it is more diffi-
cult to hide one’s errors in judgment and
choice of surgical maneuvers. The less than
“perfect nose” that we all have experienced is
frequently secondary to inadequate inter-
operative diagnoses because of an ability to
“actually see” the anatomic structures and dy-
namics involved.

Although I have been performing rhino-
plasty surgery for 20 years and feel relatively
well versed in the anatomy, dynamics and
technique of rhinoplasty, I not infrequently
encounter a nasal tip deformity that I have
difficulty correcting. Even with the nasal tip
cartilage delivery technique, I still feel frus-
trated in my ability to properly evaluate the
deformity interoperatively and to correct the
deformity to my satisfaction. The external rhi-
noplasty approach has alleviated many of my
frustrations relative to nasal tip surgery.

External rhinoplasty is not a new procedure,
but has only recently begun to gain popularity
in this country. It is not an operation in and of
itself, but is a method of gaining better surgical
exposure whereby a dorsal nasal skin flap is
elevated (Figures 1 and 2). Through this ap-
proach the nose is reshaped using conventional
rhinoplasty techniques.

* 208 E. 2nd St., North, Summerville, S. C. 29483.

** 1804 Lenora Dr., Beaufort, S. C. 29935.

FIGURE 1. Inverted V Incision and Dorsal Nasal Skin
Flap.

The dorsal nasal skin flap is made by utiliz-
ing an inverted “V” incision in the mid-col-
umella connected to bilateral marginal in-
cisions that are used in a delivery technique
(Figure 1). The flap must be handled carefully
and the underlying cartilages must not be
damaged during flap elevation. Once the dor-
sal nasal flap has been elevated, the anatomy of
the nose becomes obvious, especially that of
the nasal tip with its complicated and intricate
relationships and dynamics. This is a great
advantage in resident teaching and self-in-
struction. Hemostasis can be obtained by exact
cautery of a bleeding point, thereby further
improving visualization. With wide direct ex-
posure, trimming, suturing, repositioning and
placement of struts and/or onlay grafts can be

September 1989

425

EXTERNAL RHINOPLASTY

FIGURE 2. Direct Exposure Using Dorsal Nasal Skin
Flap.

FIGURE 3. One Year Post-op; Minimally Detectable Col-
umella Scar Following External Rhinoplasty.

done with great accuracy. Upon completion of
the operation, the dorsal nasal flap is returned
to its anatomic position and the incisions are
closed. My initial hesitancy in utilizing this
“open approach” was the noticeable scar
across the columella; however, with careful
approximation and meticulous suturing of
both skin and subcutaneous tissue, this con-
cern of an unsightly, obvious scar has not ma-
terialized (Figure 3).

Indications for the open approach are many
and varied, but usually relate to better ex-
posure in complicated, deformed nasal tips,
revision rhinoplasty, placement of grafts, se-
verely scoliotic noses and nasal septums, and
in resident teaching. It is also indicated in
excision of nasal tumors, repair of nasal septal
perforations, and trans-nasal sphenoidotomy.

There are no specific contra-indications to
an open procedure other than the patient’s
refusal to accept a scar across the columella. A
relative contra-indication is the ability to
achieve the same results through the closed
standard rhinoplasty approach.

Complications of open rhinoplasty usually
involve post-operative swelling and tender-

ness, particularly in the area of the columella.
This is a minor complaint and usually resolves
within two weeks. The open procedure does
require more surgical time due to the length of
the incision, need for careful dissection and the
need for meticulous suturing.

Although the open rhinoplasty approach
does not guarantee a successful result, it does
facilitate the understanding and proper inter-
operative diagnoses, along with allowing the
surgeon to correct the deformity under direct
vision. This in combination with the proper
execution of a surgical plan will frequently lead
to a better surgical result. □

REFERENCES

1. Adamson, Peter A.: Open Rhinoplasty. The Oto-
laryngologic Clinic of North America, November,
837-851, 1987.

2. Goodman W. S.: External Approach to Rhinoplasty,
Journal Otolaryngology 2 (3) 207-210, 1973.

3. LaNasa, James, Jr., M.D.: Personal Communication,
Baton Rouge, Louisiana.

4. Snell, G. Ed: History of External Rhinoplasty. Journal
Otolaryngology 7 (1) 6-8, 1978.

5. Strelzow, Victor V.: External Septorhinoplasty — Ap-
proach to Septal Surgery. Facial Plastic Surgery Vol. 2
(1), 1984.

426

The Journal of the South Carolina Medical Association

ADJUNCTIVE PROCEDURES IN SURGERY
OF THE AGING FACE

PAUL T. DAVIS. M.D.*

CALHOUN D. CUNNINGHAM, M.D.**

Rhytidectomy (face lift) and blepharoplasty
(eye lift) are the basic procedures in rejuvena-
tion of the aging face. Adjunctive procedures,
forehead lift, lipo-suction, chin augmentation,
cheek augmentation, chemical peel, collagen
injection, hair transplantation and permanent
eyeliner are commonly done simultaneously
or as separate procedures to improve or en-
hance the rejuvenation of the aging face.

.Almost all surgery for rejuvenation of the
aging face is done in an ambulatory or office
surgical facility which decreases cost and
makes it available to more people. Many celeb-
rities have been very open about having facial
plastic surgery which has resulted in increased
acceptance by the population. Improvements
in technology, a better understanding of facial
anatomy, facial dynamics and improved and
newr surgical procedures have improved results
and decreased complications.

During the past two decades, society has
placed a greater emphasis on diet, fitness and
youth. There is an increased emphasis on qual-
ity of life. The population is getting older, re-
maining healthier and is more concerned with
staying in the mainstream of society. The
above have resulted in an increased demand
for and acceptance of facial plastic surgery.
Facial Plastic and Reconstructive Surgery is a
sub-specialty of Otolaryngology-FIead & Neck
Surgery. Surgery for rejuvenation of the aging
face comprises a major portion of the practice
of many Otolaryngology-FIead & Neck Sur-
geons.

FOREHEAD LIFT

The forehead or coronal lift (Fig. 1 ) is usually
done by making an incision in the scalp pos-
terior to the hair line from temple to temple.
The forehead is elevated in the sub-galeal plane
down to the superior orbital rim. The procerus

* 506 East Cheves St., Suite 101. Florence. S. C. 29501.

**915 Medical Circle, Myrtle Beach. S. C. 29577.

and corrugator muscles are sometimes re-
moved. partially or completely, to lessen the
glabella frown lines. The frontalis muscle may
be divided to minimize forehead wrinkling.
The forehead flap is pulled superiorly and pos-
teriorly to correct eyebrow ptosis, improve lat-
eral orbital wrinkling and decrease forehead
lines. The forehead lift is often done in con-
junction with a face lift procedure. The fore-
head lift done in the traditional method raises
the hair line which is acceptable in most pa-
tients. Modifications include a hair line or
mid-forehead incision to avoid the superior
and posterior hair line displacement. When the
hair line incision is employed, it is beveled so
that hair grows through the resultant scar, plac-
ing the scar within the hair line. The procedure
is done under local anesthesia and complica-
tions which include numbness and thinning of
the hair are infrequent and usually resolve with
time.

LIPO-SUCTION

Lipo-suction is the removal of fat using a
blunt tipped cannula attached to a suction ma-
chine (Fig. 2). The cannula is pushed through
the fat, breaking up fatty lobules which are
removed through an aperture on the side of the
cannula behind the tip. The blunt tip pushes
large vessels and nerves aside allowing safer,
more controlled removal of fat than the tradi-
tional open surgical dissection. Fat may be
removed from the submental, cervical, neck,
jowl, and nasolabial areas as indicated with the
lipo-suction technique.

Lipo-suction is often done in conjunction
with a rhytidectomy. The aperture of the suc-
tion cannula is convenient to remove the fat
from the Superficial YTuscular ripemeurotic
System beneath the flaps raised during face lift
surgery. The subsequent clean fascial system
can be plicated or excised to tighten the facial
muscular system, resulting in a longer-lasting
face lift with fewer complications than using

September 1989

429

THE AGING FACE

FIGURE 1: Female with brow ptosis and forehead wrinkling corrected with a coronal lift in conjunction with a face lift. (Left:
Pre-op; Right: Post-op, one year.)

skin excision alone for obtaining the lift as was
done in the past. Facial lipo-suction may be
performed under local anesthesia, and the
minimal bruising and swelling allows the pa-
tients to resume their normal activities in a few
days.

CHEMICAL PEEL AND
DERMABRASION

Chemical Peel (Fig. 3) and dermabrasion
(Fig. 4) remove the epidermal and a portion of
the dermal layers of the skin. The depth of both
can be controlled. Dermabrasion is controlled
mechanically, and the depth of the chemical
peel is controlled by the nature of the chemical
used and by the concentration of the chemical.
Most cosmetic surgeons use chemical peeling
for rejuvenation of the aging face or for wrin-
kling, and reserve dermabrasion for scarring.
The chemical peel may be done either with
trichlorocetic acid or a phenol mixture known
as Baker’s formula. The trichlorocetic acid peel
is more superficial and is used for light or
superficial wrinkling. The outcome is not as

lasting and is less dramatic than that produced
with the phenol peel. With either type peel a
burn is created by the chemical. This results in
erythema and peeling, as in a sunburn, with a
low strength trichlorecetic acid peel. The
deeper phenol peel produces a second degree
burn, resulting in crusting which lasts for up to
ten days. During the crusting phase, as new
epithelium forms, the skin is erythematous for
about six weeks, but this can be concealed with
makeup. After the erythema subsides, hypo-
pigmentation sometimes develops, depending
on the depth of the peel. Chemical peeling is
frequently done before, after, or in conjunction
with facial rejuvenation surgery.

CHIN AUGMENTATION
Chin augmentation (Fig. 5) is the procedure
used to correct a weak chin or micrognathia
and is accomplished under local anesthesia
through an intra-oral or submental incision.
Usually an alloplastic material is implanted
over the anterior mandible under the chin
which results in more projection of the chin.

430

The Journal of the South Carolina Medical Association

THE AGING FACE

FIGURE 2: Patient with excess submento-cervical fat treated with suction assisted lipectomy and chin augmentation. (Left:
Pre-op; Right: Post-op.)

FIGURE 3: Female with excess facial skin and deep wrinkling treated with face lift followed by phenol chemical peel. (Left:
Pre-op; Right: Post-op.)

September 1989

431

THE AGING FACE

FIGURE 4: Female with acne scarring treated with dermabrasion. (Left: Pre-op; Right: Post-op.)

This is sometimes accomplished by an os-
teotomy of the inferior-anterior portion of the
mandible. The procedure can be done alone
but often it is done in conjunction with a
rhytidectomy, lipo-suction or rhinoplasty.
Complications are minimal but include infec-
tion and asymmetry. Bruising is minimal and
the patients can usually continue their daily
activities after a few days.

CHEEK AUGMENTATION
High cheek bones have been popularized by
Sophia Loren and other celebrities, and cheek
augmentation surgery has developed over the
past two decades. Under local anesthesia using
an intra-oral or blepharoplasty incision, an al-
loplastic material is placed over the malar
prominences increasing the projection of the
cheeks. Bruising and swelling are usually mini-
mal and resolve in a few days. Complications
are rare and include infection and asymmetry.
The patient can resume his or her normal daily
activities in a few days. The operation is done
alone or in conjunction with a rhytidectomy,
lipo-suction, rhinoplasty or blepharoplasty.

COLLAGEN

Wrinkles, scars and other depressions in the
skin may be improved or corrected by the
injection of collagen into the defect. The col-
lagen is gradually absorbed but persists for six
to 1 8 months. The results are longer-lasting in
less mobile areas such as forehead wrinkling
and disappears more quickly in more mobile
areas such as perioral wrinkling. The patient
must be tested for sensitivity since about five
percent of the population is allergic to the
product. If no sensitivity is evident after one
month, the collagen is injected into the de-
pressed areas with a fine needle. The patient
usually can return to normal activities even
though some ecchymosis occurs in a few pa-
tients. Often, several injections are required to
obtain maximal improvement and they are
done two to four weeks apart.

SUMMARY

Acceptance of surgical treatment for re-
juvenation of the aging face has increased over
the past two decades. Face lift (or rhytidec-

432

The Journal of the South Carolina Medical Association

THE AGING FACE

FIGURE 5: Female with facial wrinkling, microganthia, and brow ptosis treated with face lift, chin augmentation, and
coronal lift. (Left: Pre-op; Right: Post-op.)

tomy) and blepharoplasty remain the basic
procedures used in this surgery. Adjunctive
procedures such as forehead lift, lipo-suction,
chemical peel, chin augmentation, cheek aug-
mentation, collagen injections, hair transplant
and permanent eyeliner have been developed
to enhance the results of surgery for rejuvena-
tion of the aging face. All of this surgery can be,
and usually is, accomplished using local anes-
thesia with intravenous sedation in an am-
bulatory surgical facility. □

REFERENCES

1. Beeson, W. H., and McCollough, E. G. Aesthetic Sur-
gery of the Aging Face, St. Louis-Toronto: C. V. Mosby
Company, 1986.

2. Dedo, D. D. “Liposuction of the Head and Neck.”
Otolaryngology-Head and Neck Surgery. December,
1987; 97 (6): 591-2.

3. Elson, M. L. “Clinical Assessment of Zyplast Implant:
A year of experience for tissue contour correction.”

Journal American Academy of Dermatology. April,
1988; 18 (4 Pt. 1): 707-13.

4. Lomax, W; Schwenzfeier, C. W. “Recent Advances in
Cosmetic Facial Surgery.” J. S. C. Medical Associa-
tion. August, 1984. 80 (8): 405-7.

5. McCollough, E. G., and Hillman, R. A. “Chemical
Face Peel.” Otolaryngology Clinics of North America.
13:353-365, 1980.

6. Menick, F. J. “Artistry in Aesthetic Surgery. Aesthetic
Perception and the Subunit principle.” Clinical Plastic
Surgery. October', 1987; 14 (4):723-35.

7. Osguthorpe, J. D.; Lomax, W. R. “Facial Plastic Sur-
gery in an Otolaryngology Training Program.” Laryn-
goscope. October, 1985; 95 (10): 1255-7.

8. Pitanguy, I.; Mayer, B.; Brentano, J.; Mueller, P. M.
“Rhytidoplasty: Perioperative Guidelines. Particular
Technical Basic Details.” Laryngol., Rhinol., Otol.
(Stuttg). November, 1987; 66 (11): 586-90.

9. Siemian, W. R.; Samiian, M. R. “Malar Augmenta-
tion using Autogenous Composite Conchal Cartilage
and Temporalis Fascia.” Plastic Reconstructive Sur-
gery. September, 1988; 82 (3): 383-94.

10. Vila-Rovira, R. “Liposuction and Facial Lifting.” Fa-
cial Plastic Surgery. Fall, 1986; 4 (1): 19-23.

September 1989

433

From

Route 16...

DIZZINESS: CURRENT EVALUATION

WARREN Y. ADKINS, M.D.*
WILLIAM J. FRAVEL, M.D.**

Evaluation of the dizzy patient is frequently
a difficult diagnostic problem. A systematic
approach is necessary to establish a definitive
diagnosis, when possible, and to rule out dan-
gerous disease processes when one is not
made.1’ 2 All patients with significant dizziness
need a careful history and physical examina-
tion. The examination entails a neurological
evaluation and appraisal for spontaneous, gaze
and positional nystagmus and fistula testing,
i.e., strong positive and negative pressure to
the external auditory canal with a pneumat-
icotoscope to see if dizziness and/or nystagmus
is elicited. Ophthalmologic and/or psychiatric
evaluation may be indicated. The screening
chemistries commonly include thyroid, serol-
ogy for syphilis, determination of cholesterol,
triglycerides and blood sugar levels. An au-
diometric survey for speech discrimination
and retrocochlear abnormalities is indicated.
Any significant abnormalities discovered by
the above are addressed, and specific and/or
supportive therapy instituted. •

In developing a scheme for further assess-
ment, the patients are separated into those
with nonspecific dizziness and those with ver-
tigo. The two groups are further divided into
those with normal and abnormal audiometric
findings. A flow diagram can then be worked
out with a number of common paths between
groups (Table 1).

Patients with nonspecific dizziness and a
normal audiometric outcome are given a trial
with supportive therapy. If they remain symp-
tomatic, an Electronystagmic evaluation
(ENG) is performed and the sinusoidal har-
monic acceleration test (SHAT) considered.
When normal, posturography testing (move-
ment coordination and sensory organization)
may be indicated, and if it is abnormal, further

* Department of Otolaryngology and Communicative
Sciences, Medical University of South Carolina, 171
Ashley Avenue, Charleston, S. C. 29425-2242.

** 1639 Brabham Avenue, Columbia, S. C. 29204.

neurological evaluation and a Magnetic Reso-
nance Imaging (MRI) should be considered.
With no other new findings, symptomatic
treatment is followed. In selected cases, phys-
ical therapy may be beneficial.

If the ENG and/or SHAT findings are abnor-
mal indicating a peripheral problem, specific/
or symptomatic therapy and follow-up are pur-
sued. If there is no improvement, posturogra-
phy is considered. If the ENG deviations are
nonspecific or point to a central nervous sys-
tem defect, an MRI is indicated and when
abnormal, otoneurologic, neurologic or neu-
rological intervention is indicated.

An abnormal audiometric result requires
brain stem response audiometry, and when
normal, and the patient continues to be symp-
tomatic, an ENG and SHAT are completed. In
the event the brain stem response is abnormal,
an MRI is implemented with further consider-
ation pending the results.

In patients with vertigo and normal au-
diogram, and ENG plus/minus a SHAT is car-
ried out with further evaluation pending the
results. If the audiogram is abnormal, brain
stem response is added with further solution
pending the outcome.

These outlined systematic preparations will
usually lead to a specific diagnosis and treat-
ment, and avoid overlooking a significant dis-
ease process.

Within the last few years, SHAT testing and
posturography have moved from the research
laboratory to clinical applications. Confirma-
tion of their use and cost effectiveness is being
studied. SHAT is adjunctive and does not re-
place conventional ENG examination entail-
ing neck torsion, spontaneous, gaze and posi-
tional nystagmus (Hallpike and non-Hallpike).
In addition, bithermal calorics and fixation
suppression tests are incorporated. SHAT has
a greater degree of reproducibility than the
bithermal caloric tests, can be applied to pa-
tients with external canal atresia or stenosis

September 1989

441

DIZZINESS

Normal ^

Specific
Therapy

Synptamatic
Therapy

. / \

Symptomatic Asymptomatic

Follow up
Posturography

'^Abnormal

Abnormal

/■ \

Peripheral Central

Specific

Therapy

MRI

Normal

Symptomatic

Therapy

Follow 15)

Syirptamatic

Normal Abnormal

1 I

Follow up Neurosur

Neuro
Otoneuro

?Neuro

?MRI

Fhysical

Therapy

Follow Up

TABLE 1

442

The Journal of the South Carolina Medical Association

DIZZINESS

and with more reliability in patients with pre-
vious open mastoid surgery. It may also be
used to ascertain vestibular function in chil-
dren and the degree of residual function when
the patient has severe hypoactivity to caloric
irrigations.3’ 4

A commercial posturography test unit
(EquiTest) which evaluates sensory organiza-
tion and movement coordination is marketed
by Neurocom International, Incorporated, and
is based on the principle that proprioception,
visual input and vestibular function are inte-
gral to maintaining a sense of security relative
to the environment. The patient stands with
each foot on a special sensory platform which
can tilt and move backward and forward. A
180 degree visual screen in front of the subject
can tilt with, or independently of, the sensory
support. In the sensory organization portion of
the test the subject is monitored with the (1)
platform stable, visual field stable and eyes
open, (2) platform stable and eyes shut, (3)
platform stable and visual field swayed, eyes
open, (4) platform swayed, visual fields stable,
eyes open, (5) platform swayed with eyes shut
and (6) platform and visual fields swayed and
eyes open. These conditions place the stress on
different components of the balance mecha-
nism. For each test condition, equilibrium and
strategy are calculated.

In the movement coordination portion of
the test, the platforms move forward and back-
ward in small and large perturbations, as well
as with toes up and toes down. For each condi-
tion, static and dynamic symmetry, latency,
aptitude, adaptation (with repeat test) and
strategy in regaining a stable posture are re-
corded. In selected cases, improved scores with
repeat testing may signify benefits from phys-
ical therapy.5’ 6

The tests outlined advance the evaluation of
the patient with dizziness and vertigo. □

REFERENCES

1. Williams RC Jr, Adkins WY: Evaluation of dizzy pa-
tient. Journal of the South Carolina Medical Associa-
tion 74:239-241, 1978.

2. Finestone AJ: An approach to the patient with dizziness
and vertigo by the primary care physician. Evaluation
and Clinical Management of Dizziness and Vertigo.
John Wright-PSG, 1982.

3. Hamid MA, Hughes GB, Kinney SE, Hanson, MR:
Results of sinusoidal harmonic acceleration test in one
thousand patients: preliminary report. Otolaryngology-
Head and Neck Surgery 94:1-5, 1986.

4. Alberti PW, Ruben, RJ : Surgical anatomy of the ear and
temporal bone. Otologic Medicine and Surgery, Vol. 1.
Churchill Livingstone, 1988.

5 . Stockwell, CW : Computerized vestibular function tests;
an overview for the clinician. The Hearing Journal
1988:20-29.

6. Cyr DC, Moore GF, Moller CG: Clinical application of
computerized dynamic posturography. ENTechnology
1988 Sept:36-47.

PHYSICIAN RECOGNITION AWARDS

The following SCMA physicians are recent recipients of the AMA’s Physician Recognition
Award. This award is official documentation of Continuing Medical Education hours earned.

Bartolo M. Barone, M.D.

John J. Brown, M.D.
Gwendolyn M. Cambron, M.D.
Thomas S. Cerasaro, M.D.
Eugene C. Crisler, M.D.

Paul A. Deci, M.D.

Simeon G. Eaves, M.D.
Mitchell D. Feller, M.D.

Dennis J. Fisher, M.D.

Peter Frank, D.O.

Harold I. Friedman, M.D.

John H. Holliday, M.D.
James D. Holt, M.D.
Stephen A. Imbeau, M.D.
Harold H. Jeter, M.D.
Henry L. Laffitte, M.D.
Robert C. Lindemann, M.D
Andrew Mandell, M.D.

Ezra B. Riber, M.D.
Thomas E. Steele, M.D.
Boyce G. Tollison, M.D.

September 1989

443

HEARING CONSERVATION AND NEW
TECHNIQUES IN REHABILITATION*

R. STEWART BAUKNIGHT, M.D.
ROBERT C. WATERS, M.D.
ROBERT M. POLAND, M.A.

Twenty-eight million Americans suffer psy-
chologically and functionally from sensori-
neural hearing loss. The number will increase
as the population ages, and primary physicians
can expect additional inquiries regarding hear-
ing problems, the approach to which follows
two avenues. One is the prevention of deaf-
ness, and the other is the treatment of the
impairment. All persons with a hearing loss
can be helped through rehabilitative methods
including the exciting new technology in
amplification.

PREVENTION OF HEARING LOSS

Most cases of sensorineural hearing loss are
the result of the aging process and of noise
trauma. A small percentage is familial or other
disease related. Aging of the inner ear cannot
be prevented, but harmful environmental ef-
fects on the ear can be minimized. Of the
known detrimental entities, noise trauma is
the most prevalent.

It is estimated that 35 million Americans
may be exposed to potentially damaging noise
in the workplace, and this links workplace
noise to 27 percent of probable occupational
disease.1 South Carolina has prominent noise-
generating industries such as textile, tool and
wood product manufacturing.

Noise may produce a permanent hearing
loss due to destruction of inner ear structures.
This destruction is related to several factors.
These are the overall noise level, the frequen-
cies involved, the duration of exposure during
a day, the cumulative exposure in days or years
and the individual susceptibility to noise
trauma. The early stages of noise-induced
hearing loss may go unnoticed unless found by
hearing tests.

* From Easley Head and Neck Surgery, P.A., 109 Fleet-

wood Drive, Easley, S. C. 29640.

Occupationally induced health problems
prompted Congress in 1970 to pass the Oc-
cupational Safety and Health Act (OSHA)
which established standards for occupational
noise exposure. In 1972, an action level of 85
dB was established for all Hearing Conserva-
tion Programs (HCPs). South Carolina was the
first state to enforce this OSHA amendment.

In 1983 OSHA published the Hearing Con-
servation Amendment (HCA-83) which set de-
tailed rules for all industries in which workers
are unavoidably exposed to potentially haz-
ardous noise levels. The HCA-83 amendment
is the current standard.

The table below summarizes the criteria for
the establishment of a Hearing Conservation
Program and presents the permissible limits of
continuous noise exposure mandated in
HCA-83.

EQUAL-RISK NOISE EXPOSURES
CALCULATED ACCORDING TO THE 5-dB
RULE FOR STEADY-STATE NOISE.2

Sound Levels
(dBA)

Duration of Exposure
(hours per day)

HCP needed*

PEL**

100

103

1.5

100

105

110

0.5

110

115

0.25

* criterion level for which a hearing conservation (HCP)
is required by HCA-83.

** Permissible Exposure Level. Criterion level for which
an 8-hour day is permissible.

444

The Journal of the South Carolina Medical Association

HEARING CONSERVATION

HCA-83 states that any impulse or impact
noise in the workplace shall not exceed 104dB.

Effective Hearing Conservation Programs
include provisions for noise analysis, noise
control, noise protection (ear plugs, muffs),
periodic hearing measurements, action when
hearing changes, and personnel notification
and education. As physicians, we should be the
educators and leaders in this important aspect
of preventive medicine.

REHABILITATION AND
AMPLIFICATION

Of the estimated 28 million Americans that
have significant hearing loss, only 15 percent
become hearing aid users.3’ 4 And yet, ampli-
fication remains the single best approach deal-
ing with the communicative and social handi-
caps associated with deafness. Why do so few
obtain help? The primary reasons are that
many think they do not need amplification,
and that aids are too expensive and are unat-
tractive. Many believe or are told by a physi-
cian that a hearing aid cannot help.

Rehabilitative techniques such as lip read-
ing, preferential seating, optimal positioning,
sign language and family education and coun-
seling by trained and interested professionals
are beneficial to all. The communicative skills
of many neglected persons, old and young, can
be further enhanced using these techniques
plus amplification.

Conventional hearing aids have undergone
improvements to make them more acceptable
and useful. Miniaturization has made the in-
the-ear hearing aid the most popular aid today.
Additionally, automatic signal processing in
these small aids lessens loud sounds and am-
plifies soft sounds while keeping the overall
output at an acceptable comfort level for the
user. Expense is being controlled through the
use of modular preassembled circuits which
can be mass produced and fitted into the aid by
the dispenser. This feature allows immediate
delivery and on site repair and modification of
the aid by the dispenser.3

Digital hearing aid technology is foremost in
the improvements of hearing aids.5 This new
technology converts the analog sound wave
signal into a digitized binary form. This in turn
greatly expands the possibilities of signal mod-
ification to enhance, diminish, eliminate or

add to the signal. The new digitized signal is
reconverted into sound and presented to the
user. Digital technology also allows program-
ming of a single device to have different re-
sponses to a given signal. A better match
between symptom and treatment is thus possi-
ble. The digital aid now obtainable has three
programs which can be chosen by the user to
best match different listening conditions or
fluctuations in the user’s hearing.5 The current
disadvantages of the digital aid are size (not yet
miniaturized) and cost. The future should
bring improvements that revolutionize the
hearing aid industry.

The implantable hearing aid is another
promising new progression in hearing ampli-
fication.4 The device consists of a surgically
implanted electromagnet attached to the skull
or to a middle ear ossicle. Vibration is induced
in the implanted magnet by an externally worn
induction coil connected to a receiver. The
currently approved implantable aid is inserted
into the skull behind or above the ear through
an outpatient operation under local or general
anesthesia. This device is practical and avail-
able for those persons who are unable to wear a
conventional hearing aid because of a con-
genital deformity, canal stenosis, chronic otitis
or a previous mastoidectomy. Other devices
are under investigation.4

The cochlear implant is another significant
step in the understanding and treatment of
sensorineural hearing loss. This device has had
much attention in the lay press. The cochlear
implant consists of an electrode surgically
placed inside the cochlea. The electrode is con-
nected to an induction coil implanted beneath
the skin above and behind the ear. An external
induction coil connected to a body worn pro-
cessor is worn at the implant site. A sound
signal is converted into an electrical signal
which directly stimulates inner ear structures.
Several devices are available or are under
investigation.6

Cochlear implants are indicated only for the
profoundly deaf who obtain no benefit from
conventional amplification. Ideally, a candi-
date for a cochlear implant is a profoundly deaf
adult of recent onset, who has previously de-
veloped speech, has no infectious ear disease,
is highly motivated and has at least average
intelligence." Indications for children are more

September 1989

445

HEARING CONSERVATION

stringent. The cochlear implant does not re-
store normal hearing. Generally, users can de-
tect sounds at normal levels, are able to
discriminate between some sounds, recognize
a few words in context and monitor the level of
their own voice. The most consistent results
are that users develop better lip reading ability
and are more aware of their surroundings.
Cochlear implantation is more than surgery.
The process includes preoperative and postop-
erative training by a qualified team, which
consists of audiologists, speech pathologists,
physicians, psychologists and the patient’s
family.8

In addition to hearing aids, there exists a
large category of devices designed to help im-
prove communication and awareness in the
hard of hearing. These consist of alerting and
signaling devices such as buzzers, flashing
lights or vibrators. They are used to aid detec-
tion of smoke alarms, alarm clocks, turn sig-
nals and others. Personal listening devices and
amplifiers are available for the radio, tele-
phone, lecture halls and for other personal
needs.

Hearing loss in many patients can be pre-
vented, and all can be helped. The primary
physician can be aware of the prevalence of the
problem and detect cases by history and
screening tests in the office. When appropriate,
referral can be made to qualified health care
providers. □

REFERENCES

1. Miller MH: Occupational Hearing Conservation Pro-
grams. Seminars in Hearing, Vol. 9, No. 4, 299-306,
1988.

2. Osguthorpe, JD: Guide For Conservation of Hearing in
Noise, 7th Revision Pub., American Academy of
Otolaryngology-Head and Neck Surgery Foundation,
Inc., Washington, D. C.

3. Smriga DJ: Developments in Hearing Aid Fitting and
Delivery. OTO Clinic of North American, Vol. 22, No.
1, 105-127, Feb. 1989.

4. Maniglia AJ: Implantable Hearing Devices: State of the
Art. OTO Clinic of North America, Vol. 22, No. 1,
175-201, Feb. 1989.

5. Hecox KE: Digital Hearing Aid Technology: Medical
Perspective, OTO Clinic of North America, Vol. 22,
No. 1, 129-142, Feb. 1989.

6. Balkany TJ: The Cochlear Implant, OTO Clinic of
North America, Vol. 19, No. 2, May 1986.

7. Black, FO: Consensus Development Conference on
Cochlear Implants. Hearing Instruments, Vol. 39, No.
9, 52, 1988.

8. House WF: Questions and Answers About the Cochlea
Implant, Version III, Walt Disney Hearing Rehabilita-
tion Research Center, L.A., California 1980.

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446

The Journal of the South Carolina Medical Association

MANAGEMENT OF POST-INTUBATION AND
POST-TRAUMATIC AIRWAY STENOSIS

LUCINDA A. HALSTEAD, M.D.*
JAMES T. BOWLES, M.D.**

Stenoses of the larynx and trachea from
trauma or intubation are seen regularly by the
otolaryngologist-head & neck surgeon. Pro-
longed endotracheal intubation in adults re-
sults in pressure injuries in the posterior glottis
and the trachea. While high volume, low pres-
sure cuffs have substantially reduced the tra-
cheal incidence, glottic stenosis remains un-
changed.1 A prospective study of 200 patients
revealed 14% of patients intubated more than
10 days had severe laryngeal strictures.2 Long
term intubation used in the management of
neonates since 1965 is now the most common
source of subglottic stenosis in infants and
children.3 While existences as high as 20% were
documented in the 1 970s, current reports place
acquired subglottic stenosis in neonates be-
tween 4-8. 5%.3 Trauma to the larynx and tra-
chea has supplanted infection as the next
major cause of airway constriction.4 Trau-
matic stenoses can occur at any level (su-
praglottic, glottic, subglottic or tracheal) de-
pending upon the site of injury (hyoid, thyroid
cartilage, cricoid or trachea).

Airway stenoses emanate from the loss of
cartilage and soft tissue or from the prolifera-
tion of dense granulation tissue followed by
scar formation. The type of repair depends on
the nature of the stenosis. Until the mid- 1 970s,
treatment consisted largely of bypassing the
pertinent segment with a tracheotomy and
treating the stenosis by dilatation, stenting,
tracheal grafts, or tracheal resection. Advances
in carbon dioxide (C02) laser microlaryn-
goscopy and bronchoscopy since the 1970s
have made endoscopic treatment of many air-
way stenoses possible and often avoids trache-
otomy.

The management of laryngeal and tracheal

* Department of Otolaryngology and Communicative
Sciences, 171 Ashley Avenue, Charleston, S. C.
29425-2242.

**110 East Medical Lane, West Columbia, S. C. 29169.

stenoses requires careful appraisal of laryngeal
function and the involved site. Fiberoptic
laryngoscopy allows an undistorted, unhurried
evaluation of laryngeal function. Bilateral vo-
cal cord paralysis and severe glottic incompe-
tence with aspiration limits therapeutic op-
tions. Radiographic determination of the
length and diameter of the stenotic area is
important. Computed tomography (CT) and
magnetic resonance imaging (MRI) have re-
placed tomography as imaging modalities of
choice. Both give excellent assessment of soft
tissue and cartilage and are equally effective
(Figure l).5 In certain instances the sagittal
imaging capability of MRI is helpful. CT and
MRI are avoided in infants and children since
the sedation required to reduce motion artifact
makes the risk of airway obstruction in the
scanner unacceptably high. Magnification air-
way radiography excellently delineates the air-
way in infants and children without sedation
(Figure 2).6

Until the early 1970s, subglottic stenosis was
managed primarily by tracheotomy and dilata-
tion. A report by Fearon and Cotton in 1974 of
a 24% mortality among infants and children
managed in this manner has stimulated a more
aggressive approach among otolaryngologist-
head and neck surgeons.7 Suspension micro-
laryngoscopy with C02 laser excision of sub-
glottic scar tissue is the preferred method of
treatment in adults and infants at the Medical
University of South Carolina (Figure 3). The
C02 laser vaporizes scar tissue with microme-
ter precision with minimal surrounding ther-
mal damage, unlike cautery or cryosurgery,
and has been successful in both adults and
children.8'10 Over the past 16 months, tra-
cheotomy has been avoided in nine of 10 in-
fants with severe subglottic stenosis utilizing
this technique. When laser is unsuccessful in
infants, an anterior cricoid split allows the sub-
glottic area to be enlarged. Open techniques

September 1989

447

AIRWAY STENOSIS

FIGURE 1. A. & B. Axial CT scan cartilaginous tracheal
secondary to granulation tissue and scar (small arrows).

FIGURE 2. Magnification airway radiograph of subglottic
stenosis (arrows).

with cartilage grafting are practiced in infants
when the above techniques fail as well as in
adults with cartilage loss.3’ 11
Tracheal stenoses may also result from car-
tilage loss or scar proliferation. Bronchoscopic
C02 laser has been highly effective in excising
tracheal cicatricial tissue. The C02 wavelength
is preferred over the Nd-YAG and KTP wave-
lengths since it volatilizes tissue with minimal

stenosis (small arrows). C. Sagittal MRI of tracheal stenosis

FIGURE 3. Subglottic stenosis as seen during suspension
microlaryngoscopy with C02 laser excision. TVC-true vo-
cal cords, arrows-stenosis.

surrounding thermal harm.12 In cartilage in-
jury, tracheal resection with reanastomosis
provides excellent results.13

Supraglottic and posterior glottic stenoses
continue to be difficult management problems
with either laser or open techniques. Laser
treatment has prevailed on well delineated in-
terarytenoid fibrous bands and supraglottic
stenoses.9

448

The Journal of the South Carolina Medical Association

AIRWAY STENOSIS

In summary, the surgical management of
post-traumatic and post-intubation airway ste-
noses has dramatically expanded since the
mid-1970s. The C02 laser has made the most
impact on the management of airway stenoses
by well founded endoscopic surgery and avoid-
ing tracheotomy in many cases. □

REFERENCES

1. Weymuller EA: Laryngeal injury from prolonged en-
dotracheal intubation. Laryngoscope 98(pt. 2): 1-15,
1988.

2. Whited RE: A prospective study of laryngotracheal
sequele in long-term intubation. Laryngoscope 94:
367-377, 1984.

3. Cotton RT and Myer CM: Contemporary surgical
management of laryngeal stenosis in children. Am J
Otolaryngol 5: 360-368, 1984.

4. Snow JB: Diagnosis and therapy for acute laryngeal
and tracheal trauma. Oto Clin North Am 17: 101-106,
1984.

5. Council on Scientific Affairs: Magnetic resonance
imaging of the head and neck region. JAMA 260:
3313-3326, 1988.

6. Macpherson RI and Leithiser RE: Upper airway
obstruction in children: an update. RadioGraphics 5:
339-375, 1985.

7. Fearon B and Cotton RT: Surgical correction of sub-
glottic stenosis of the larynx in infants and children:
progress report. Ann Otol Rhinol Laryngol 83:
428-431, 1974.

8. Holinger LD: Treatment of severe subglottic stenosis
without tracheotomy. Ann Otol Rhinol Laryngol 91:
407-412, 1982.

9. Dedo HH and Sooy CD: Endoscopic laser repair of
posterior glottic, subglottic and tracheal stenosis by
division or micro-trapdoor flap. Laryngoscope 94:
445-450, 1984.

10. Duncavage JA, Piazza LS, Ossoff RH, et al: The mi-
crotrapdoor technique for the management of
laryngeal stenosis. Laryngoscope 97: 825-828, 1987.

11. Cummings CW, Sessions DG, Weymuller EA, et al:
Atlas of laryngeal surgery. CV Mosby Co, 1984.

12. Shapshay SM, Beamis JF, Hybels RL, Bohigian RK:
Endoscopic treatment of subglottic and tracheal ste-
nosis by radial incision and dilatation. Ann Otol Rhi-
nol Laryngol 96: 661-664, 1987.

1 3. Grillo HC: Tracheal reconstruction. Arch Otolaryngol
96: 31-39, 1972.

On tlje Cover:

The cover illustration is from a hand-
colored lithograph by Dr. J. M. Bougery pub-
lished in Paris in 1832 (“Traite Complet de
L’Anatomie de L’Homme”). Lithography, “to
draw on stone,” was introduced by Sennefelder
in Germany in 1796 as a less costly alternative
to the copper plate engraving. The image was
drawn on finely polished limestone with a
greasy ink and then a thin layer of water was
poured onto the tablet. Paper was then pressed
against the stone, and the elevated ink image
was transferred and the non-image area was
wetted with water. When the paper dried, the
lithograph could be colored by hand. The im-
age of this lithograph was probably inked on
zinc, which was an improvement from the
fragile limestone. Mechanization of lithograph
coloring was introduced in the 1930s, and uti-
lized successive pressings with separate plates
for each color. The original Currier and Ives
pastoral scenes were printed with such a
process.

The early anatomists and surgeons were one

and the same. As structural and functional
relationships were defined, surgical techniques
were created or altered accordingly. The first
oncologically-sound operation for cervical me-
tastases, the en bloc radical neck dissection
promulgated by Hayes Martin in the 1940s,
was based on careful study of the cervical
lymphatics. As revealed by the cover litho-
graph, these lymphatics were well not deline-
ated in the mid- 19th century. The newer
“conservative” neck dissections which remove
specific cervical lymphatics while preserving
the internal jugular vein, spinal accessory
nerve and/or sternocleidomastoid muscle
were also developed in the anatomy and au-
topsy laboratories prior to use on cancer pa-
tients. Future developments in surgery will
continue to depend on cooperation between
the anatomist, pathologist, physiologist and
surgeon.

— J. David Osguthorpe, M.D.

Guest Editor

September 1989

449

Bcltoriai

OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Prior to 1892, there were 11 states repre-
sented in the American Laryngological Asso-
ciation (1878), and in that year Dr. W. Peyre
Porcher of Charleston was elected as the first
Fellow from the south. Later he became Presi-
dent of the S. C. Medical Association and im-
plemented the republication of a state medical
journal which had been suspended since 1877
because of the slow post-War Between the
States recovery. By 1893, Otolaryngology was
being presented in all of the post graduate U. S.
medical colleges.

Of significance in the development of the
specialty was the establishment of a school of
Otolaryngology after World War I at a Camp
Greenleaf, Chickamagua Park, Georgia, which
was the forerunner of the American Board of
Otolaryngology (predated only by Ophthal-
mology). Recognizing a lack of knowledge of
the fundamentals of the field as well as allied
sciences, perceptive leaders concluded that
standardization entailing a satisfactory exam-
ination for certification was needed to sort out
the untrained, self-styled specialist.

The advent of antibiotics in the 40s, the
maturing of anesthesia and the experience
gained during World War II pertaining to fluid
and blood replacement, shock and trauma in-
fluenced a dra matic shift from control of infec-
tion and its complications to other dimen-
sions. During this period, many eminent prac-
titioners predicted dissolution of the Otolaryn-
gology specialty. Far from limiting its sphere,
radical procedures for head and neck neo-
plastic diseases opened up. Since control of the
air and food passageways via the laryngo-phar-
yngeal complex to insure adequate respiration
and prevent aspiration is vital to major head
and neck surgery, it was natural that the evolu-
tion come through Otolaryngology with its
particular proficiency in these specific needs.
To remain in the mainstream and with the
guidance of the Board of Regents of the Ameri-

can College of Surgeons, training in underlying
general surgical principles became a prerequi-
site in residency programs (currently at least
one year of general surgery in the five year
minimum of postgraduate training), which ac-
celerated expansion into a regional specialty
which includes facial plastic and reconstruc-
tive, orbital, neurotologic and skull base pro-
cedures. Technologic refinements in lasers,
endoscopic telescopes and surgical micro-
scopes have been appropriated into sinus,
otologic and laryngeal disorders.

The trend towards effective chemotherapy
and irradiation in combined therapy for ad-
vanced head and neck cancer, along with tech-
nical advances in skull base (intracranial-
extracranial) ablation operations and recon-
struction with regional myocutaneous or mi-
crovascular flaps are expected to intensify in
the coming decade. Progress in glossoman-
dibular restoration with osseous components
and a functional transplanted or artificial
larynx, unsuccessful in the past, may be re-
vived in the future.

The recent formation of the National In-
stitute of Deafness and Other Communication
Disorders should promote further investiga-
tions into the regeneration of the hair cells of
the human inner ear (as discovered in certain
fish), digital hearing aids, and cochlear and
internal auditory implants, especially in pro-
foundly deaf infants and children.

Taking into account the present and antici-
pated directions, subspecialization within
Otolaryngology/Head and Neck Surgery in the
tertiary care and university centers seems
likely to continue.

F. Johnson Putney, M.D.
Professor Emeritus
Dept, of Otolaryngology
MUSC, 171 Ashley Ave.
Charleston, S. C. 29425

450

The Journal of the South Carolina Medical Association

SCMA HEALTH PROJECTS: 1989-90

The South Carolina Medical Association Auxiliary Health Projects Committee is enthusiastically
committed to its ongoing goals and ideals. For the year 1 989-90, we hope to promote health care in
our 27 organized counties by combining their efforts to promote health education and total well-
being of all South Carolinians. In addition, we would hope that such efforts will serve to inform the
public of the many services and deeds quietly volunteered by those of the medical profession,
thereby re-emphasizing the positive role of the medical community.

In keeping with the goals of the Comprehensive Health Education Act, the AMA and SCMA
auxiliaries continue to work on the early childhood and adolescent health initiatives to insure the
healthy development of all. These goals will vary from one county to the next; however, each
program will meet definite immediate needs and contribute to a healthy community. Examples of
programs begun in response to the AMA initiative are those which deal with substance abuse,
sexuality and pregnancy, victimization, psychological disorders and suicides, trauma and violence,
and more recently, HIV education.

Our more recent accomplishment, of which we are quite proud, is the Health Education Van.
Through the combined efforts of our county auxiliaries, medical societies, and other dedicated
individuals, we achieved our dream of a mobile classroom which would travel to schools within our
state, promoting health and education to our students. This is a hands-on experience guided by
totally committed and enthusiastic health educators. Additionally, South Carolina is the first state
to conceive such an idea, and through 100% participation in less than 1 5 months, have it become a
reality.

.Along with the Health Education Van, we continue to endorse the Physicians’ Family Support
Committee; a fall and winter board (each board meeting focuses on health issues and also utilizes
exhibitors from area health organizations such as the American Cancer Society, the American Red
Cross, the Council on Drug and Alcohol Abuse, etc., who are on hand to share educational
materials, ideas and resources with our members); annual school nurses’ workshops (in conjunction
with the South Carolina Department of Education and the South Carolina Department of Health
and Environmental Control); and numerous other community projects.

Also, we also support the smoke-free policy adopted just recently by area hospitals and health
facilities in hopes that in the near future we will have a smoke-free society.

To coincide with national “Talk About Prescriptions” Month in October, we hope to sponsor a
statewide campaign to encourage older citizens and their physicians to review their medications. In
this way, we would hope to achieve our goal of improving physician/patient understanding and
communication.

As co-chairmen of the Health Projects Committee, we look forward to working with each
auxilian, physician and individual to promote the many issues of health care in each area. We
welcome your input and appreciate your support in all areas to assure our state of a successful and
productive year.

Joanne Dunovant and
Kathy Evans, Co-Chairmen
SCMAA Health Projects Committee

September 1989

451

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OCCUPATIONAL MEDICINE: An oppor-
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INDEX TO ADVERTISERS

B & B X-Ray 407

C&S Bank 397

Charter Rivers Hospital Cover 2

Freud Symposium 408

G Geisler Group 420

Hamilton Industries Cover 2

Eli Lilly & Company 414

The Mahaffey Agency 420

Medical Protective Company 419

Medical Software Management, Inc 412

National Emergency Services 408

Palisades Pharmaceuticals 420

Ridgeview Institute 401

Roche Laboratories Cover 3, Cover 4

U.S. Air Force 408

U.S. Army Reserve 402, 413

U.S. Navy 398

Walton Rehabilitation Hospital 412

Winchester Surgical Supply Company 446

Winthrop 434, 435, 436

452

The Journal of the South Carolina Medical Association

/ OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

VOLUME 85

OCTOBER 1 989

NUMBER 10

HOW GOOD (OR BAD) IS THE PAP SMEAR?

WILLIAM T. CREASMAN, M.D.*

It has been almost a half century since Papa-
nicolaou and Traut published their mono-
graph on what today has become known as the
Pap smear. Because of other worldwide ac-
tivities at that time, its acceptance was post-
poned and was really not implemented until
the 1960’s and 70’s. Even in the early 1 970’s it
was estimated that only 50% of the adult
women had ever had a Pap smear and only
25% on a “regular” basis. Fortunately, at the
present time it is estimated that over 90% of
the adult women in the United States have had
at least one Pap smear and that some 60% have
a Pap smear on a regular basis (at least every
three years).

The Pap smear was the first, and until re-
cently the only screening technique that has
been shown to be effective for cancer anywhere
in the body. Interestingly, the efficacy of the
Pap smear has never been demonstrated in a
prospective randomized study. Because of bio-
ethical considerations that study will never be
done. It has, however, been shown to be effec-
tive in reducing the incidence and mortality of
cervical cancer. Nowhere in the world has the
incidence of invasive cancer decreased without
an active screening program. A good example
of its efficacy is a study from Iceland where,
prior to the introduction of screening, the mor-
tality from cervical cancer had been rising.
Once screening was established, the annual
mortality rates began to decline and now are
less than half of the rate that was present in the

* Department of Obstetrics and Gynecology, Medical Uni-
versity of South Carolina, 1 7 1 Ashley Avenue, Charles-
ton, S. C. 29425.

late 1 960’s. This study is especially noteworthy
because cancers are reported through a central
registry and it is an isolated country and, there-
fore, mobility of the population is limited.
Even the harshest critics of the Pap smear all
agree that the indirect evidence is very strong
in concluding that the Pap smear has been
effective in decreasing the incidence and there-
fore the mortality of invasive cancer.

It should be remembered that an ideal
screening technique is not to identify the lesion
once it is present (i.e., invasive cancer), but to
identify its precursors (cervical intraepithelial
neoplasia — CIN) which are unidentifiable
with traditional examination. This benefit is
important as these early lesions are easily and
effectively treated. This year the American
Cancer Society estimates that 12,900 women
in the United States will have invasive cervical
cancer diagnosed and that 7,000 of these indi-
viduals will die from their disease. Yet during
the last decade the incidence of invasive cancer
has decreased by about 25%. Concomitant
with the decrease in the incidence of invasive
cancer has been the astronomical rise in the
number of patients with CIN identified. It has
been estimated that at least 200,000 women
(some estimate this figure at one million) in the
United States this year will have a diagnosis
made of CIN. Essentially all of these patients
have been identified because of an abnormal-
ity initially noted on the Pap smear.

THE PAP SMEAR CONTROVERSY

Historically in the United States there has
been a “yearly” Pap smear which was em-
pirically derived. Over the last several years

October 1989

459

THE PAP SMEAR

there have been questions raised concerning
the need of the yearly Pap smear. In 1976, the
Walton report from Canada was published and
suggested that the Pap smear could be done at a
less frequent interval and in general the “every
three-year Pap smear” was recommended.
They did, however, recognize a group of
women who were at increased risk for develop-
ing cervical cancer, and these women should
be screened annually. In the early 1980’s, the
American Cancer Society essentially endorsed
the Walton report with some modification.
After the American Cancer Society’s recom-
mendation was published, several other orga-
nizations including the American College of
Obstetricians and Gynecologists suggested
that there was validity in the annual Pap smear
at least for a significant number of our popula-
tion. The “Pap Smear Controversy” erupted.
This led to a considerable amount of confusion
by both medical personnel and the public. Sub-
sequent data accumulated in British Columbia
(which represents probably the best screened
population in the world) noted that carcinoma
in situ rates for screened females had increased
appreciably during the 1970’s (two-fold or
greater in the 20 to 44-year-old groups and five-
fold in the 20 to 24-year-old groups). As a result
the Walton Commission, in 1982, rescinded
their 1976 recommendations and essentially
recommended a yearly Pap smear, particularly
for those who were at risk. After considerable
discussion among many of the professional
groups in the United States, including the
American College of Obstetricians and Gyne-
cologists, the American Cancer Society, and
the National Cancer Institute, a year ago a new
recommendation was endorsed by these bodies
which stated: “All women who are or who have
been sexually active, or have reached age 18
should have an annual Pap smear and pelvic
examination. After a woman has had three or
more consecutive satisfactory normal annual
examinations, the Pap smear may be per-
formed less frequently at the discretion of her
physician.” The fellowship of the American
College of Obstetricians and Gynecologists
have generally interpreted this to be an en-
dorsement of the yearly Pap smear.

FALSE NEGATIVE PAP SMEAR
About the time that the Pap smear contro-

versy was being resolved, a new concern was
voiced. How good was the Pap smear? Al-
though this question had been addressed to
some degree in the medical literature, it was
not until a series of articles appeared in the
Wall Street Journal, that resulted in the Pulit-
zer Prize for the author, did this issue become a
national concern. The false negative rate with
anecdotal examples became front page news.
The false negative Pap smear rate was quoted
as being between 20 and 40%. That data was
based upon studies several decades old, most
of which were few in number. Mathematical
modeling was then done to predict a suspected
false negative rate. These figures may or may
not be correct. We really do not know what the
false negative rate is for the Pap smear. Recent
data would suggest that those figures may be on
the low side. Yet even if these percentages are
correct, no one denies the benefit of the Pap
smear. Two areas have been addressed as to
the reasons for this relatively high false nega-
tive rate, one being the clinician (inappropriate
technique in obtaining the Pap smear) and the
other, the cytology laboratory. It has been sug-
gested that each of these two factors are equally
at fault, although where that conclusion is de-
rived from is not known.

The Clinician’s Responsibility
It is well-recognized that neoplastic lesions
of the cervix begin in the so-called transforma-
tion zone. This is the area on the cervix that
was originally columnar epithelium but during
the midadolescent years was transformed by
the process of squamous metaplasia into
squamous epithelium. As a result, the Pap
smear must be taken from this area. The Ayre
spatula is commonly used to remove cells from
this area. Since disease can extend up the canal,
a specimen from this area either with the modi-
fied Ayre spatula, os aspirate or saline moist-
ened cotton-tipped applicator has been recom-
mended. More recently, a brush-like apparatus
has been developed which does increase the
number of cells obtained from the endocervix.
The two specimens (exocervix and endocer-
vix) can be placed on a single or separate glass
slides and then fixed immediately by whatever
technique the cytologist recommends. The va-
ginal pooled specimen is inappropriate and is
not recommended in screening for cervical

460

The Journal of the South Carolina Medical Association

THE PAP SMEAR

neoplasia. Properly obtained Pap smear
should decrease the chance of missing abnor-
mal cells if in fact the cervical lesion is present.
It should be remembered, however, that if a
lesion is seen on the cervix even in the presence
of a normal Pap then further evaluation is
indicated including a biopsy. It is not unusual
to see a gross cervical cancer and yet the patient
will have a normal Pap smear. As stated ear-
lier, the Pap smear is not to identify those
patients who already have an invasive cancer
as our clinical examinations can usually do
that very well.

Cytology Laboratory

Much attention has been focused on this
area as the reason for the high false negative
Pap smear rate. Overworked cytotechnologists
reading Pap smears at home on the kitchen
sink, and quality control of the laboratory have
all received considerable lay press. It is appre-
ciated that “Pap mills” have been in existence
in the United States and have become popular
because of their low cost ($2-3) and in many
cases a high false negative rate. As a result of
some of this recent publicity, Congress has
addressed this problem and new Federal reg-
ulations have been approved effective 1 Janu-
ary 1989 to govern laboratories including those
who do cytology (unfortunately the regulations
have not been issued to date). It is recognized
that cervical cytology by nature is not 100%
accurate and that currently it is an art and not a
pure science. There are, however, several
guidelines a clinician can use in order to deter-
mine the probability that the laboratory is
doing a good job.

(a) Although certification of the laboratory
is currently voluntary, the fact that the
facility has submitted to this peer review
suggests the importance they place on
documenting their quality control. The
American College of Pathology and the
American Society of Cytology, among
others, evaluate and certify cytology lab-
oratories. In some states laboratory cer-
tification is required.

(b) There must be good communication be-
tween the clinician and the cytology lab-
oratory. It is important for the clinician
to be able to discuss the cytology report
with the cytologist so that difficult cases

can be resolved. Ideally, the cytology
and the pathological material from the
patient should be reviewed in the same
laboratory.

(c) The laboratory should be willing to no-
tify the clinician when the cytological
smear is unsatisfactory or otherwise
uninterpretable.

(d) The laboratory should be run by a physi-
cian-cytologist who is trained in pa-
thology with additional expertise in the
interpretation of cytology specimens.
All positive or suspicious smears should
be reviewed by the cytologists.

(e) The laboratory should have an adequate
number of cytotechnologists for the case
load.

WHO SHOULD BE SCREENED?

It is well-recognized that there are several
important epidemiological factors which ap-
pear to be extremely important in this disease
entity. It is appreciated that this is a sexually
transmitted disease. The onset of sexual inter-
course in the midadolescent years and multiple
sexual partners are factors that identify' females
at risk. It is also recognized that smoking ap-
pears to be an independent risk factor for this
disease entity. Since the process of active
squamous metaplasia is going on during the
midadolescent years, it makes sense that the
onset of sexual activity during this time frame
increases the risk for this disease entity. Multi-
ple sexual partners probably relates to a dose
phenomenon more than anything else. The
development of CIN can occur within a short
time after the onset of sexual activity. In a
study from Duke University it was noted that
30% of patients with biopsy proven CIN were
20 years of age or younger at the time of diag-
nosis and that one-half of these patients had
the diagnosis established within five years of
the commencement of sexual activity.

For many years the significance of the male
factor was not appreciated in this disease pro-
cess but it is recognized today that there are
high risk males. These individuals practice sex
with more than one woman and in many cases
with prostitutes. Multiple sexual exposures
promotes the development and spread of sexu-
ally transmitted agents to their partner and
certain types of papilloma virus have been

October 1989

461

THE PAP SMEAR

implicated in the genesis of genital squamous
carcinoma. Women in monogamous mar-
riages are considered at low risk for cervical
cancer; however, we now recognize that many
of these women are placed at high risk by their
partners. With the present trend toward higher
divorce rate, it is likely that even truly low risk
women will eventually have multiple sexual
partners and move into a higher risk group. It
is said tht 50% of all married women and
70-80% of all married men have had multiple
sex partners. About half of all 16-year-olds
have had more than one sex partner. Certainly,
the current recommendation of commence-
ment of screening once the individual is sexu-
ally active is prudent advice.

Recent data suggest that 25% of all cervical
cancer occurs in patients over 65 years of age
and that over 40% of all cancer deaths occur in
this age group. The prevalence of abnormal
Pap smears is high in this age group and the
chance of developing an invasive cancer is not
necessarily related to prior screening habits in
this age group. Therefore, it appears that even
though an individual may fall into this age
range and has had numerous normal Pap
smears, screening should really continue dur-
ing an individual’s lifetime.

RECOMMENDATIONS
The agreed upon previously mentioned Pap
smear frequency recommendation appears
valid:

“All women who are or who have been sexu-
ally active or have reached age 18 should
have an annual Pap smear and pelvic exam-
ination. After a woman has had three or
more consecutive satisfactory normal an-
nual examinations, the Pap test may be per-
formed less frequently at the discretion of
her physician.”

Although this recommendation can be subject
to varied interpretation, an annual Pap smear
and exam appears to be prudent. Certainly
those individuals at high risk should have an
annual Pap smear. Those individuals in the
low risk category may very well be placed un-
knowingly at high risk by their sexual partner
even though their activities place them at low
risk. It is well appreciated that there are not

many individuals who really satisfy the “three
or more consecutive, satisfactory, normal, an-
nual examinations” as the probability for all of
those requirements to be satisfied is very low.
The experience from British Columbia would
suggest that when a woman is asked to return
for an annual examination, she does so on the
average of every 22 months. A recommenda-
tion of longer than one year could result in
examinations at less than optimal intervals.
Because of the high risk for developing cancer
in the older patient, Pap smears should be
continued for the life of the individual.

Even with the admitted problems and ad-
verse comments, the Pap smear remains the
outstanding example of what screening for a
cancer can accomplish. In 1930, more females
died from uterine cancer than any other malig-
nancy. During the ensuing years there has been
a precipitous drop (70%) in deaths of cervical
cancer so that many other cancers account for
many more deaths. Although much has been
accomplished we cannot become complacent
and must continue to recommend to our pa-
tients the need for continued screening as sug-
gested above. □

SUGGESTED REFERENCES

1. Shy K, Chu J, Mandelson M, et al: Papanicolaou
smear screening interval and risk of cervical cancer.
Gyn Oncol 26:409, 1987.

2. Berman DM, McMillan JP, Creasman WT: Papanico-
laou smear history of patients developing cervical can-
cer: Assessment of screening protocols. Obstet. Gynec.
69:151, 1987.

3. Canadian Task Force: Cervical cancer screening pro-
grams. Summary of the 1982 Canadian Task Force
Report. Can. Med. Assn. J 581, 1982.

4. Mandelbalatt JS, Faks MC: The cost effectiveness of
cervical cancer screening for low income elderly
women. JAMA 259:2409, 1988.

5. Richart RM, Barron BA: Screening strategies for cer-
vical cancer and cervical intraepithelial neoplasia.
Cancer 47:1176, 1981.

6. Gay JD, Donaldson LD, Goellner JR: False-negative
results in cervical cytologic studies. Acta Cytol
29:1043, 1985.

7. Tawa K, Forsythe A, Cove JK et al. A comparison of
the Papanicolaou smear and the cervigram: Sen-
sitivity, specificity, and cost analysis. Obstet. Gynec.
71:229, 1988.

8. Creasman WT and Weed JC Jr.: Conservative man-
agement of cervical intraepithelial neoplasia. Clin
Obstet Gynec 22:281, 1980.

9. Papanicolaou, GN and Traut HF: The diagnostic
value of vaginal smears in carcinoma of the uterus.
Am J Obstet Gynec 42:193, 1941.

10. Wall Street Journal, February 2, 1987.

462

The Journal of the South Carolina Medical Association

UTILIZATION OF AMNIOCENTESIS AND
CHORIONIC VILLUS SAMPLING BY
SOUTH CAROLINA WOMEN 35 YEARS
OF AGE AND OLDER*

CAM KNUTSON, M.S.

S. R. YOUNG, Ph.D.

RONALD V. WADE, M.D.

ROBERT G. BEST, Ph.D.**

Although increasing age has been associated
with significantly higher risk for chromosome
abnormalities in pregnancy, still an estimated
4.4% of all babies in the United States are born
to women over the age of 35. Numerous stud-
ies of amniocentesis utilization have been un-
dertaken over the past decade in various parts
of the United States to determine how prenatal
diagnosis usage affects the incidence of Down
Syndrome and other genetic abnormalities,
and to determine the efficacy of health services
provision.2'5 These studies have found amnio-
centesis utilization among women 35 years of
age and older to range from less than 1% in
1972 to almost 40% in 1981 depending on
geographical location. Utilization is lower for
black women who live in rural areas.

South Carolina has a population of approx-
imately 3,376,000 with a large percentage liv-
ing in rural counties. In 1985, 1.8% of South
Carolina women had no prenatal care at all
which suggests that even routine obstetrical
care may be unavailable to some indigent rural
patients.6 This effect might be even more pro-
nounced with regard to services such as amnio-
centesis, maternal serum alpha-fetoprotein
screening, and newer tests such as DNA link-
age and chorionic villus sampling (CVS), a first
trimester prenatal diagnostic procedure.

Because the advent of CVS is so recent, uti-
lization studies have not yet been reported for
this procedure. South Carolina is unusual in

* From the Department of Obstetrics and Gynecology,
University of South Carolina School of Medicine, Co-
lumbia, S. C..

** Address correspondence to Dr. Best at Two Medical
Park, Suite 301, Columbia, S. C. 29203.

that it was one of the first in the United States
to offer CVS. Because of greater accessibility to
the test, women in South Carolina might be
expected to use CVS more than women in
other southeastern states or rural areas.

To date, there have been few reported stud-
ies on prenatal diagnosis in states which have a
high percentage of the population living in
rural areas. The purpose of this study was to
quantify utilization of prenatal diagnostic op-
tions among South Carolina women 35 years
of age and older during a two year period and to
investigate possible correlations between uti-
lization rates and specific demographic vari-
ables such as ethnic background, socioeco-
nomic level and geographic location. Util-
ization rates were investigated for amniocen-
tesis and chorionic villus sampling in South
Carolina resident women over the age of 35.
This study encompassed the first year in which
CVS was offered and the year preceding it, in
an attempt to evaluate whether the introduc-
tion of CVS as a prenatal diagnostic alternative
has had a significant impact on the utilization
of amniocentesis.

RESULTS

For the year 1985, 2,578 out of 51, 856 (4.9%)
total live births in South Carolina were to
women 35 and older. Similarly for 1986, there
were 2,720 out of 51,726 (5.26%) total live
births to older women. The total number of
amniocentesis procedures performed in-
creased from 1985 to 1986, however, the per-
centage of amniocenteses for women 35 years
of age and older dropped from 74.8% to 62.5%.
Of the 191 total CVS procedures performed in

October 1989

463

AMNIOCENTESIS

1986, 158 were for women 35 years of age or
older.

There were an an estimated 534 pregnancies
in both 1985 and 1986 to women over the age
of 35 who received their primary prenatal care
through South Carolina county health depart-
ments. Black patients accounted for 70.6% of
the total with the remaining 29.4% patients
predominantly white.

In 1985, there were 949 amniocenteses per
2,578 live births to women 35 and older giving
a utilization rate of 36. 8%. In 1986, 928 amnio-
centeses were performed out of 2,720 live
births to women ages 35 and older giving a
utilization rate of 34.1%. CVS utilization was
found to be 5.8% in the advanced maternal age
group for 1986. Thus, the overall utilization
rate for 1986 was 39.9%. The decrease in the
total number of advanced maternal age amnio-
centeses from 1985 to 1986 was found to be
significant, (p = .02). However, the addition of
CVS as a prenatal diagnostic alternative has
significantly increased overall prenatal diag-
nosis utilization (p=.0099).

Utilization of amniocentesis, CVS, and
combined amniocentesis and CVS by county
for the most recent year, 1986, are shown in
Table 1. Since physician’s county of residence
rather than maternal county of residence was
recorded at the genetic center in Charleston,
those data are excluded from county utiliza-
tion calculations. However, since most
Charleston referrals come from the nine sur-
rounding counties, those numbers are com-
bined to give a pooled utilization estimate for
the “Low Country” region. Using known am-
niocentesis or CVS utilization rates for each
year, the expected number of amniocentesis or
CVS procedures was calculated for each
county for which data were available, and Chi
Square analysis was used to identify those
counties whose utilization rates differed signif-
icantly from the average utilization for the
state (Table 1). Overall, eight counties were
found to have rates significantly lower than the
average utilization rate. Conversely, Richland
county and the pooled Low Country region
had significantly greater utilization rates.

During 1985, amniocentesis was performed
on 590 white patients, 1 42 non-whites, and 2 1 6
whose race was not recorded. In 1986, there
were 466 amniocenteses on whites, 168 on

non-whites, and 294 whose race was unre-
corded. Chorionic villus samples were ob-
tained from 1 54 whites and four blacks during
1986. There were 1,573 total white live births
to women above age 35 in 1 985, and 1 ,005 non-
white. In 1 986, there were 1,618 total white live
births and 1,102 non-white live births among
women above age 35. Adjusting for the propor-
tion of amniocenteses of unknown race, there
was a significant decrease in prenatal diagnosis
test utilization between different racial groups
in both years studied. In 1985, whites had a
utilization rate of 41.0% while non-whites had
a rate of 15.4% (p<.001). In 1986, overall pre-
natal diagnosis utilization among whites over
35 years of age was 43.0% compared with
17.5% for non-whites (p<.001)

A highly significant racial difference was ob-
served for CVS utilization. 97.5% of the CVS
procedures performed on women above age 35
were to white patients. Utilization rates were
10.7% and 0.4% for whites and non-whites
respectively (p< .00 1 ).

Counties were identified as urban if the
county population size was greater than
200,000 people. Only four counties in South
Carolina could be classified as urban: Charles-
ton, Greenville, Richland and Spartanburg.
Since maternal county of residence was not
recorded in the Low Country Region data,
these numbers were excluded from data cal-
culations. Amniocentesis utilization was
47.1% for urban women in 1985 compared
with 29.0% for rural women (p<.001). Simi-
larly for 1986, amniocentesis utilization was
38.2% for urban woman and 26.2% for rural
(p<.001). CVS utilization rates were 14.2%
and 3.7% for urban and rural patients respec-
tively (p<.001). Overall prenatal diagnosis
rates for 1986 were 52.3% for urban and 29.8%
for rural patients (p<.001).

Significant differences across the board were
also found for utilization by private referrals
compared with health department referrals.
While part of the observed difference would be
expected based on the racial distributions of
the two groups, analysis of health department
referrals showed significantly lower prenatal
diagnosis utilization rates than expected with
race correction for both 1985 and 1986. The
observed utilization rate for health department
patients in 1985 was 11.2% compared with a

464

The Journal of the South Carolina Medical Association

AMNIOCENTESIS

TABLE 1

AMNIOCENTESIS, CHORIONIC VILLUS SAMPLING (CVS) AND
OVERALL PRENATAL DIAGNOSIS UTILIZATION RATES BY
SOUTH CAROLINA COUNTIES FOR 1985 AND 1986

County

1985

Amnio

1986

Amnio

1986

CVS

1986

Total

Abbeville

26.1

13.0

0.0

13.0

Aiken

27.8

24.7

0.0

24.7

Allendale

33.3

22.2

0.0

22.2

Anderson

37.8

48.6

0.0

48.6

Bamberg

42.9

53.3

6.7

60.0

Barnwell

30.8

22.2

0.0

22.2

Beaufort

42.7*

42.9*

1.1

44.0#

Berkeley

42.7*

42.9*

1.1

44.0#

Calhoun

25.0

50.0

12.5

62.5

Charleston +

42.7*

42.9*

2.6

45.5#

Cherokee

0.0

4.2

0.0

4.2

Chester

4.2

11.5

3.8

15.3

Chesterfield

8.7

16.7

0.0

16.7

Clarendon

6.1

10.7

0.0

10.7

Colleton

42.7*

42.9*

0.0

42.9#

Darlington

42.5

29.3

9.8

39.0

Dillon

5.9

11.1

5.6

16.7

Dorchester

42.7*

42.9*

2.9

45.8#

Edgefield

11.1

38.5

0.0

38.5

Fairfield

35.7

14.3

4.8

19.0

Florence

21.5

28.4

2.9

31.4

Georgetown

42.7*

42.9*

4.3

47.2#

Greenville +

40.7

42.3

5.1

47.4

Greenwood

27.0

33.3

0.0

33.3

Hampton

42.7*

42.9*

0.0

42.9#

Horry

42.7*

42.9*

1.9

44.8#

Jasper

42.7*

42.9*

0.0

42.9#

Kershaw

23.5

12.5

15.6

28.1

Lancaster

30.0

18.2

0.0

18.2

Laurens

21.7

38.1

0.0

38.1

Lee

18.2

23.5

0.0

23.5

Lexington

48.0

28.1

9.4

37.5

McCormick

12.5

16.7

0.0

16.7

Marion

14.3

3.8

0.0

3.8

Marlboro

4.5

0.0

4.8

Newberry

47.6

11.1

14.8

25.9

Oconee

25.0

44.4

0.0

44.4

Orangeburg

25.3

39.5

1.3

40.8

Pickens

16.0

9.1

4.5

13.6

Richland +

64.6

37.1

25.5

62.6

Saluda

50.0

9.1

0.0

9.1

Spartanburg +

21.4

32.6

5.4

38.0

Sumter

34.7

25.0

2.8

27.8

Union

6.3

15.4

0.0

15.4

Williamsburg

42.7*

42.9*

0.0

42.9#

York

27.5

36.0

6.0

42.0

* rate calculated from pooled data from ten Low Country counties served by Charleston genetic center.

# includes pooled amniocentesis utilization rate and CVS rate

+ signifies county classified as urban (population greater than 200,000)

Percentage of eligible (i.e., 35 years of age and older) women in each South Carolina county who had amniocentesis (amnio)
or CVS performed in 1985 or 1986.

October 1989

465

AMNIOCENTESIS

race corrected expected rate of 22.93%
(pC.OOl). For 1986, the observed utilization
was 9.9% compared with an expected rate of
25.0% (pC.OOl). CVS, although available to
approximately one third of the health depart-
ment patients (patients served by one of the
three genetic centers), was used exclusively by
private referrals.

DISCUSSION

In recent years, there has been an expansion
of genetic services for prenatal diagnosis. Nu-
merous studies have been made to determine
the utilization and availability of these services
to eligible women.3- 7 This study examined
amniocentesis and CVS utilization among
South Carolina women 35 years of age and
older in order to ascertain the extent to which
genetic services were accessible and available
to this group, and to measure what effect CVS
had, if any, on amniocentesis utilization.

Other researchers have predicted that uti-
lization of prenatal diagnosis, specifically am-
niocentesis, would continue to increase year by
year.3- 4 This effect was noted in the South
Carolina data as total utilization of prenatal
diagnosis increased from 1985 to 1986. The
decrease in amniocentesis utilization reflects
the fact that a significant portion of the over-35
population are now opting for the earlier CVS
test. As CVS becomes more established, one
might expect the percentage of advanced ma-
ternal age women choosing amniocentesis to
continue to decrease.

South Carolina’s overall utilization rate of
39.9% was greater than might be expected from
a state with a predominantly rural population.
In a study limited to women over the age of 40,
Sokal et al.,8 found utilization rates in a rural
population to be as low as 9%. Although New
York utilization rates were 35.3% in 19809 and
40% in 1 98 1 , 10 utilization rates in other parts of
the country are typically lower.3 Ohio reported
a 23.4% utilization rate for 19834 which is well
below the current South Carolina rate. Thus, it
appears that utilization of genetic services in
South Carolina is comparable to published uti-
lization rates from other areas of the United
States.

The utilization rate for CVS of 5.8% is per-
haps surprising considering the newness of the
test. By contrast, early utilization rates for am-

niocentesis in 1972 were found to be as low as
0.2 1%.4 Given the rapid acceptance of CVS
among South Carolina physicians and patients
during the first complete year for which the
procedure was offered and the continuing in-
crease in demand (unpublished observation),
it appears that CVS has the potential to over-
take amniocentesis as the prenatal diagnostic
procedure of choice by older women.

Utilization rates for South Carolina counties
in 1986 ranged from 3.8% to 62.6% indicating a
wide disparity among counties (Table 1). The
county rates supported findings from previous
studies which report lower utilization rates in
rural counties and higher rates in urbanized
areas.3’ 4 Seven counties had rates below 15%.
According to Hook et al.,10 rates of 15% or less
suggest that not all eligible women are aware of
the procedure or that facilities currently cannot
meet the demand for services. Since facilities
for South Carolina are and have been sufficient
to meet the demand for genetic services, there
may be a need for educational programs in
these counties to increase patient awareness.

South Carolina’s utilization rates support
the findings in previous studies where
utilization rates were generally noted to be
higher among white women than non-white
women.3- 4> 9 From the total number of live
births to South Carolina women over the age of
35 for 1985, 61.0% of births were to white
women and 39.0% births were to non-whites.
By contrast, 80.6% of all amniocenteses were
for white women and only 1 9.4% were for non-
white women. It is puzzling why this difference
should exist. Other authors have not found
significant racial differences in attitude toward
abortion which might affect utilization.9 Per-
haps there are underlying differences in at-
titudes toward medical care or in the social
structure of the family (e.g. attitudes towards
the raising of a handicapped child) which could
account for the low observed utilization of
prenatal diagnosis among non-white women.

A significant difference was also found in the
utilization between private physician and
health department referrals. Utilization was
typically much greater for private patients.
While prenatal testing is available at no cost to
all advanced maternal age patients receiving
primary prenatal care through county health
departments in South Carolina, transportation

466

The Journal of the South Carolina Medical Association

AMNIOCENTESIS

problems to and from genetic centers and other
financial constraints may contribute to the low
observed utilization in this population as well.

SUMMARY

An increase in utilization of prenatal diag-
nosis was observed from 1 985 to 1986 in South
Carolina. The overall rate of 39.9% for 1986 is
comparable with other areas of the U.S. Uti-
lization was correlated with geographic resi-
dence, race, and referral source. While there
was considerable variation in prenatal diag-
nostic test utilization between counties in
South Carolina, overall utilization rates were
reasonably high and continued to increase
from 1985 to 1986. It will be interesting to see
what effect CVS has on overall utilization rates
as this new procedure becomes more estab-
lished throughout the state. □

REFERENCES

1. Roghmann KJ, Doherty R, Robinson JL, Nitzkin JL,
Sell, RR: The selective utilization of prenatal genetic
diagnosis: experiences of a regional program in upstate
New York during the 1970s. Med Care 1983;
21:1111-1125.

2. Luthy DA, Emanuel I, Hoehn H, Hall JG, Powers EK:
Prenatal diagnosis and elective abortion in women
over 35: utilization and relative impact on birth preva-

lence of Down Syndrome in Washington State. Am J
Med Genet 1980; 7:375-381.

3. Adams MM, Finley S, Hansen H, Jahiel RI, Oakley
GP, Sanger W, Wells G, Wertelecki W: Utilization of
prenatal diagnosis in women 35 years of age and older
in the United States, 1977 to 1978. Am J Obstet
Gynecol 1981; 139:673-677.

4. Naber JM, Huether CA, Goodwin BA: Temporal
changes in Ohio amniocentesis utilization during the
first twelve years (1972-1983) and frequency of chro-
mosome abnormalities observed. Prenat Diag 1987;
7:51-65.

5. Huether C: Projection of Down Syndrome births in
the United States 1979-2000 and the potential effects
of prenatal diagnosis. Am J Public Health 1983;
73:1186-1189.

6. South Carolina Department of Health and Environ-
mental Control. South Carolina Vital and Morbidity
Statistics, 1985. Volume I, Annual Vital Statistics
Series.

7. Doherty R, Roghmann K: Knowledge, attitudes and
acceptance of prenatal diagnosis among women and
physicians in the Rochester region. In: Porter I, Hook
(eds): Service and Education in Medical Genetics.
New York: Academic press, 1979.

8. Sokal DC, Byrd JR, Chen ATL: Prenatal chromo-
somal diagnosis: racial and geographic variation for
older women in Georgia. JAMA 1980; 244:1355-1357.

9. Hook EB, Schreinemachers DM: Trends in utilization
of prenatal cytogenetic diagnosis by New York state
residents in 1979 and 1980. Am J Public Health 1983;
73:198-202.

10. Hook EB, Schreinemachers DM, Cross PK: Use of
prenatal cytogenetic diagnosis in New York state. N
Engl J Med 1981; 305:1410.

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468

The Journal of the South Carolina Medical Association

IDIOPATHIC ARTERIOVENOUS RENAL
VASCULAR MALFORMATION TREATED
BY EX VIVO REPAIR*

WILLIAM R. MORGAN, M.D.

JAMES A. MAJESKI, M.D., Ph.D.**

Renal arteriovenous malformation was first
reported by Varela in 1928, who described the
lesion discovered at autopsy in a 27-year-old
man.1 The improvement of imaging tech-
niques has made this entity more easily diag-
nosed and more than 200 cases have been
reported.2

Renal arteriovenous fistulas may be easily
detected by a variety of noninvasive imaging
techniques and therefore are now being readily
identified in asymptomatic patients being
evaluated for other reasons. This case de-
scribes a patient with a typical idiopathic or
aneurysmal type of renal arteriovenous mal-
formation (AVM) detected incidentally during
evaluation after a motor vehicle accident.

CASE REPORT

A previously healthy 44-year-old white male
was the unrestrained driver in a single motor
vehicle accident. He was hypotensive at the
scene (systolic blood pressure of 45mm Hg.)
and was transferred to this institution via heli-
copter. Six liters of lactated Ringer’s solution
were infused and MAST trousers were applied
during transit. On arrival the patient’s blood
pressure was 110/67. There was a severe lac-
eration involving the left arm with arterial
bleeding. Physical examination revealed no
signs of abdominal or flank trauma, no audible
bruits and no palpable abdominal masses.
Chest x-ray demonstrated no evidence of car-
diomegaly or heart failure. Other injuries in-
cluded a fracture dislocation of the left
acetabulum and a closed head injury. Uri-
nalysis results revealed six to ten red blood
cells per high power field. Intravenous pyelo-

* From the Departments of Urology and Surgery, Medi-
cal University of South Carolina, Charleston, S. C.

** Address correspondence to Dr. Majeski at the Depart-
ment of Surgery, Medical University of South Carolina,
Charleston, S. C. 29425.

gram showed prompt function, however, there
was a suggestion of a mass in the hilum of the
right kidney. Computed tomography of the
abdomen revealed a five by six centimeter vas-
cular lesion involving the hilum of the right
kidney. (Figure 1)

Arteriography (Figure 2) further delineated
the lesion as a smooth, thin-walled vascular
mass involving an upper pole segmental ar-
tery. No early venous filling was demon-
strated. There was no extravasation and no
retroperitoneal hematoma. The preoperative
diagnosis was traumatic pseudoaneurysm.
After stabilization the patient was taken to the
operating room and explored through a mid-
line abdominal incision. Vascular control of
the renal vessels was obtained from the mid-
line. The right colon was reflected and the right
kidney was explored. There was no evidence of
renal trauma and no retroperitoneal hema-
toma. A pulsatile mass could be palpated in the
hilum of the kidney. Because of the intrarenal
nature of the lesion, it was determined that an
ex vivo approach would more easily afford a
renal conserving repair of what was initially

FIGURE 1. Computerized tomogram.

October 1989

469

RENAL VASCULAR MALLORMATION

FIGURE 2. Right renal arteriogram.

felt to be a pseudoaneurysm. The renal vessels
were ligated and divided at their origins. The
ureter was mobilized to the pelvic brim. The
kidney was perfused with cold heparinized
Ringer’s lactate solution. Ex vivo exploration
demonstrated a large sacular malformation of
the renal artery in continuity with the venous
circulation which had not been demonstrated
on arteriography. There was no hematoma or
inflammatory change to suggest that the lesion
was related to the recent trauma. On the con-
trary, the vascular walls appeared well formed,
suggesting a previously existing chronic phe-
nomenon. The venous channel was ligated and
the artery was reconstructed with multiple in-
terrupted 6-0 prolene sutures. The renal unit
was then transplanted to the right pelvis in an
inverted position with vascular anastamosis to
the common iliac vessels. Postoperative renal
scan confirmed normal renal function bilater-
ally and the patient recovered uneventfully.
Pathologically the arteriovenous fistula was
confirmed from the tissue removed during the
operative procedure.

DISCUSSION

Renal arteriovenous malformations may be
classified as either congenital or acquired.
Congenital fistulas have a cirsoid appearance
angiographically with multiple arteriovenous
communications. Acquired fistulas are smooth,
round, solitary and may result from a variety
of causes including percutaneous renal biopsy,

trauma, fibromuscular dysplasia, surgery and
malignancy.3 A third category, idiopathic or
spontaneous arteriovenous malformations
(AVM) are typically aneurysmal in appearance
with smooth and round borders.

Angiographically similar to acquired fistu-
las, these lesions may be congenital or arise
from an unknown acquired etiology.4 Some
investigators have suggested that they arise
from a congenital aneurysm of the renal artery
which spontaneously ruptures into a nearby
vein.5 Because no previous predisposing fac-
tors were present in this case and the an-
giographic appearance was not typical for the
cirsoid type, this patient’s fistula falls into the
idiopathic or aneurysmal group. Most patients
with renal arteriovenous fistulas present with
symptoms directly related to the lesion, such as
heart failure, renal ischemia, (hypertension) or
bleeding. Hematuria has been reported to oc-
cur in 33% to 65% of cases and is found more
often in the congenital variety. Other common
clinical findings include: abdominal bruits
(75%), cardiomegaly (57%), diastolic hyperten-
sion (50%) and pain (34%).6

The diagnosis is usually confirmed an-
giographically with demonstration of early
venous runoff. This however was not seen in
this case, leading to a preoperative diagnosis of
traumatic pseudoaneurysm, which led to a sur-
gical exploration. Nadjafi reported a similar
case in which venous runoff was not seen on
arteriography and diagnosis was also delayed
until arteriovenous connections were con-
firmed at surgery.7 In patients with post renal
biopsy fistulas, management has traditionally
been conservative as approximately 70% will
close spontaneously within 18 months. Expec-
tant management of traumatic AVM’s other
than post renal biopsy has been less successful
and surgical repair is often required.5’ 6

Small asymptomatic congenital lesions may
be followed conservatively in selected cases.8
Follow up studies must be obtained as asymp-
tomatic lesions have been known to enlarge
rapidly during conservative observation and
expectant management is not without risk.9
Intervention is generally indicated for symp-
tomatic lesions not secondary to renal biopsy.
Recently, transcatheter arteriographic em-
bolization has been employed using a wide
variety of occlusive agents. Risks include re-

470

The Journal of the South Carolina Medical Association

RENAL VASCULAR MALFORMATION

currence, renal infarction, hypertension and
pulmonary embolization through the fistula.5
When aneurysmal or occlusive disease is pres-
ent, open surgical repair is more effective.10
Partial or total nephrectomy is the traditional
form of therapy. More recently, renal sparing
techniques have become popular. Simple liga-
tion of feeder vessels is associated with distal
infarction as well as a significant rate of recur-
rence. Ligation of individual vessels and ar-
terial reconstruction is the favored approach.6
A direct approach to the vessels may, however,
be technically difficult. With the advent of
bench surgery, exposure of these lesions has
improved making reconstruction more feasi-
ble. The technique of ex vivo renal surgery is
well described and has been employed by oth-
ers for repair of renal arteriovenous fistulas.
Three such cases have been reported in the
literature. Dean employed the technique in a
repair of a congenital renal arteriovenous
fistula.11 Nadjafi used an ex vivo approach to
salvage a failed repair of a renal AV fistula7 and
Munda repaired an arteriovenous calyceal fis-
tula in a functioning living related transplant
also using an ex vivo technique.12 The basic
principle of ex vivo surgery of the kidney has
allowed for the salvage and repair of many
organs which otherwise would have been lost.
The indications for renal autotransplantation
are still evolving. A working knowledge of this
technique should be in the armamentarium of
the surgeon who treats renal disease. The tech-
nique should be kept in mind when dealing
with renal tumors, trauma and vascular lesions
especially in patients with a solitary kidney.
The most common indication for extracor-
poreal surgery on the kidney today is reno-
vascular occlusive disease. Advantages include
a bloodless field, use of an operating micro-
scope if necessary, unhurried application of
microvascular techniques and the ability to
obtain autogenous vessels, either artery or
vein, for reconstruction. The first autotrans-
plant was performed by Hardy for an iatro-
genic ureteral injury in 1963. The ureter is
usually left intact in most of these procedures
but easily can be reimplanted into the bladder
if necessary.

The trauma surgeon should be able to em-
ploy this technique if the patient is stable and

other life threatening injuries do not add any
further risk to the operative procedure. Extra-
corporeal renal surgery in the trauma situation
can occasionally be hastened by a two-team
approach. The incidence of complications
from the use of ex vivo surgery of the kidney is
low. The use of this technique has been re-
ported for splitting a horseshoe kidney for use
in transplantation surgery.

In conclusion, renal AVM is an unusual dis-
ease which is being diagnosed with more fre-
quency. For symptomatic lesions renal con-
serving treatment is favored. When surgical
reconstruction is indicated an ex vivo ap-
proach provides excellent exposure making re-
pair more feasible. This approach was used in a
44-year-old trauma victim who was explored
because of a suspected renal artery pseu-
doaneurysm which at surgery was found to be a
renal arteriovenous malformation. □

REFERENCES

1. Varela M E: Anerisma arteriovenoso de los vaso re-
nales y asistolia consontiva, Rev. Med. Latino-Am.
14:3244 (1928).

2. Tynes W V II: Unusual renovascular disorders, Urol.
Clin. North Am. 11:529 (1984).

3. Oxman H A, Sheldon G S, Bematz P E, and Harrison
E G Jr: An unusual cause of renal arteriovenous
fistula-fibromuscular dysplasia of the renal arteries,
Mayo Clin. Proc. 48:207 (1973).

4. Takaha M, Matsumoto A, Ochi K, Takeuchi M, Take-
soto M, and Sonoda T: Intra renal arteriovenous mal-
formation, J. Urol. 124:315 (1980).

5. Morin R P, Dunn E J, and Wright C B: Renal ar-
teriovenous fistulas: A review of etiology, diagnosis,
and management, Surgery 99:114 (1986).

6. Messing E, Kessler R, and Kavaney P B: Renal ar-
teriovenous fistulas, Urology 8:101 (1976).

7. Nadjafi S, Brech W, Piazolo P, and Wengler D: Seg-
mental renal autotransplantation in a patient with a
single kidney affected by arteriovenous malformation
and aneurysm, Am. J. Surg. 141:605 (1981).

8. Kopchick J H, Bourne N K, Fine S W, Jacobsohn H A,
Jacobs S C, and Lawson R K: Congenital renal ar-
teriovenous malformations, Urology 17:13 (1981).

9. Yazaki T, Tomita M, Akimoto M, Konjiki T, Kawai
H, and Kumazaki T: Congenital renal arteriovenous
fistula: Case report, review of Japanese literature and
description of non-radical treatment, J. Urol. 1 16:415
(1976).

10. Cho K J and Stanley J C: Non-neoplastic congenital
and acquired renal arteriovenous malformations and
fistulas, Radiology 129:333 (1976).

1 1 . Dean R H, Meacham P W, and Weaver F A: Exvivo
renal artery reconstructions: Indications and tech-
niques, J. Vase. Surg. 4:546 (1986).

12. Munda, R, Alexander J W, First M R, Laver M C, and
Majeski J A: Autotransplantation and ex vivo surgery
for renovascular disease, Arch. Surg. 1 16:772 (1981).

October 1989

471

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472

The Journal of the South Carolina Medical Association

NEWSLETTER

OCTOBER 1989

MEDICAID UPDATE

Coverage Extended to Children up to Age Seven

Medicaid covers children age one to six if they live in families
with income below 100 percent of poverty. As of October 1,
Medicaid coverage has been extended to children up to age seven
if their family income is below 100 percent of poverty.

Medicaid Coverage for the Aged. Blind and Disabled

Medicaid coverage for the aged, blind and disabled with income
below 100 percent of the federal poverty guidelines began
October 1, 1989. Medicaid already covered aged, blind and
disabled persons who had Part A Medicare benefits, income below
100 percent of the federal poverty guidelines and resources
below certain guidelines. These persons are Qualified Medicare
Beneficiaries ( QMBs ) . The new coverage group allows persons who
meet these same income and resource guidelines to be eligible
for Medicaid even if they do not have Part A Medicare.

With reference to existing coverage (prior to October 1) for
QMBs, less than 1,500 have been approved for Medicaid to date,
whereas HHSFC had expected approximately 20,000 QMBs to be
eligible by the end of 1989. The number of eligibles is
considerably lower than expected and HHSFC enlists your support
in referring the people you serve if they have (a) Part A
Medicare benefits; (b) income below $525 per month for an
individual or $700 per month for a couple; and (c) resources
below $5,500 for an individual or $9,000 for a couple.

QMBs apply for Medicaid by calling a toll free number, 1-800-922-
5936. Persons in Columbia should call 765-2312. Self-assessment
guides have been developed to help people decide if they meet the
guidelines. If you would like copies of these guides for your
waiting rooms, you may request them by calling the Division of
Eligibility at 1-253-6128.

Increased Reimbursement Rates

In an effort to improve access to quality medical care for
Medicaid recipients,' HHSFC has increased the physician
reimbursement rates for many commonly performed procedures.
Following is a partial list of those rates which are effective
for dates of service on or after July 1, 1989.

Description

Before 7/1

After 7/1

Office

Visit

Code

90010 New patient (limited) $25.00 $30.00

90050 Established patient (limited) $18.00 $20.00

Hospital care code 90215 (Initial-intermediate History) has been
increased from $27.90 to $41.00, and code 90220 (Initial-
comprehensive History) has increased from $33.30 to $55.00.

Healthy Adult Physical Exams

Effective for dates of service on or after July 1, 1989, HHSFC

will reimburse physicians for performing adult physical
examinations. Insurance clerks should bill HHSFC for these exams
using procedure code 90750 and diagnosis code V70.9. The
reimbursement rate is $100.00.

Healthy Child Physical Exams

Healthy child (20 years of age or younger) physical exams
(screenings) are still only reimbursable through the EPSDT
program. Reimbursement is set at $45.00 for children under one
year old and $35.00 for older children and adolescents. If you
are a primary care physician and would like more information
regarding the EPSDT program, call Sandra McCord or Paul Trulley
at 1-253-6121.

Procedure Codes for Back Transfer of NICU Graduates

To encourage pediatricians and family practitioners to accept
NICU graduates back to Level I and Level II hospitals and
hopefully establish a medical home for these infants, HHSFC has
created the following procedure codes effective for dates of
service on or after July Is

Code Description

S9661 Initial Hospital Exam for an Infant
Transferred from a Level III NICU

Reimbursement

Rate

$100.00

59662 Extended or Intermediate Subsequent
Hospital Care for an NICU Graduate
Transferred from a Level III Hospital

59663 Limited or Brief Subsequent Hospital Care
for a NICU Graduate from a Level III NICU

S9660 Initial Office Visit for a NICU Graduate

$ 50.00

$ 30.00
$ 80.00

If you have questions, please call your program manager at 1-253-
6134.

PHYSICIAN BILLING UNDER CROSS-COVERAGE ARRANGEMENTS

The SCMA has received many calls from SC physicians in response
to a September 4, 1989 article in Medical Economics which
described the trouble physicians in another state encountered
with their Medicaid agency when they billed for their patients
although another physician had covered for them.

In response to an SCMA request for clarification, BC/BS of SC has
informed us that, according to the Medicare Carrier* s Manual,
Section 5211, BC/BS will allow reimbursement for "personal
identifiable services that require performance by a physician.”
However, it has been their practice as the carrier to verify
services rendered by checking to see if physicians are in
practice together or if someone else covered for the attending
physician in his/her absence. As long as both physicians have
not submitted duplicate bills or if they are rendering medically
necessary concurrent care, those services would not be
questioned.

Preliminary information from the Health and Human Services
Finance Division indicates there is no problem for physicians
billing under cross-coverage arrangements with regard to
Medicaid. However, HHSFC has requested a legal opinion prior to
issuing a more definitive statement.

SCMA HURRICANE RELIEF FUND

The SCMA is accepting contributions to provide assistance to the
many thousands of homeless in the state. A national appeal has
been made to the members of the AMA for contributions to the
relief fund which has been established. If you are able to make
a contribution, please send it to: Relief Fund, SC Institute for
Medical Education and Research, PO Box 11188, Columbia, SC 29211.
All contributions are tax deductible when checks are made payable
to SCIMER.

ATTENTION: DISABILITY DETERMINATION CONSULTANTS

The Disability Determination Division (Vocational Rehabilitation
Department) office building in Charleston was heavily damaged
during hurricane Hugo. Although temporary office space is being
prepared, case processing operations have been transferred to the
Columbia office until preparations are completed. Physicians who
perform consultative examinations on Social Security Disability
applicants scheduled by the Charleston office, and who need to
contact that office, should call the Charleston office telephone
number and it will be automatically routed to the Columbia
office. Those physicians who dictate reports into the Charleston
Tele-Dictation system should continue to use the same telephone
number. Dictation will automatically be routed into the Columbia
office Tele-Dictation equipment for processing.

All consultative physicians in the following counties are urged

to call the Charleston office telephone number (1-800-868-0100)
and advise of any changes in office location, telephone number or
scheduling changes so that the scheduling unit can make contact:
Horry, Williamsburg, Georgetown, Berkeley, Dorchester,
Charleston, Colleton, Hampton, Beaufort and Jasper. Normal
examination scheduling may be temporarily disrupted; however, it
should return to normal when necessary repairs are completed to
the Charleston office.

REPORT FROM THE SCMA YOUNG PHYSICIANS' SECTION

Gerald E. Harmon, MD, Chairman of the SCMA Young Physicians'
Section, has submitted the following report on the AMA Young
Physicians Assembly held in Chicago in June, 1989:

The assembly considered 31 resolutions and nine governing counsel
reports, with 12 resolutions being sent for consideration to the
AMA House of Delegates. An additional five resolutions will be
sent to the House of Delegates at the 1989 AMA Interim meeting.
The Young Physicians' Section voiced its opposition to tobacco
sales to minors, mandatory Medicare expenditure targets as well
as regional or national reimbursement caps, and unrestricted sale
and ownership of assault weapons. The section voiced support for
a maternity leave policy for physicians in practice, child care
at national conferences, cholesterol screening, nutrition
education, and participation in organized medicine by minority
physicians.

A resolution was made that the AMA conduct a survey to evaluate
potential problems with voluntary health screening programs
regarding the possible accuracy and efficacy as well as
communicative problems for those programs not directed by a
physician. A young physician, Dr. Nancy Dickey, was elected to
the AMA Board of Trustees at this meeting.

Delegate Steven Hulecki, MD, has reported a number of problems
felt to be particularly important for young physicians. He, Dr.
Roger Gaddy and Dr. Harmon solicit the input and suggestions of
all young physicians in the state. This input can then be
provided to the AMA and the SCMA to be carried to the appropriate
legislative bodies. The Young Physicians' Section appreciates
the involvement they have had thus far and looks forward to
continued strengthening of the section with the SCMA and the AMA.
Copies of the complete reports by Drs. Gaddy and Hulecki are
available by calling Dr. Gerald Harmon at 1-527-4442 or Julia
Brennan at SCMA Headquarters.

SCMA DIRECTOR OF LEGAL AFFAIRS

The SCMA announces the employment of Stephen P. Williams as
Director of Legal Affairs effective September 15, 1989. Steve
received his BA, cum laude. from Wofford College in 1978 and his
JD from the University of South Carolina in 1981. He was in
private practice in Greenville for two years and for the last

six years has been an attorney with the SC Office of Appellate
Defense. In addition to his legal duties with the SCMA, Steve
will staff the Medical Ethics and Mediation Committees.

RETENTION OF MEDICAL RECORDS

A physician should take the following time periods into
consideration for determining the length of time to store his or
her patient records:

1. Malpractice Considerations

The Statute of Limitations for medical malpractice actions is
three years from the date of discovery or when it reasonably
ought to have been discovered, not to exceed six years from the
date of occurrence. Disabilities, such as mental incompetence or
imprisonment of the patient, can extend this period for an
additional five years.

If the action concerns the placement or leaving of a foreign
object in the body, the action must be commenced within two years
from the date of discovery or when the defect reasonably ought to
have been discovered; provided that in no event shall there be a
limitation on commencing the action less than three years after
the placement or leaving of the apparatus.

Physicians treating minors should note that an action could be
brought up to 13 years from the date of the procedure leading to
the lawsuit or claim. These time periods apply to cases arising
or accruing after April 5, 1988.

2. Physicians should notify their patients of their retirement
or closing of the office to make arrangements for transfer of the
patient's records to another physician. The retiring physician
should keep the original file and make copies for the patient.
The same is true for a physician closing his office for reasons
other than retirement.

Questions about these matters may be directed to Steve Williams,
Director of Legal Affairs, at the SCMA.

THE CENTER FOR REHABILITATION TECHNOLOGY SERVICES

The South Carolina Department of Vocational Rehabilitation has
established the Center for Rehabilitation Technology Services,
one of two national rehabilitation engineering centers funded to
address service delivery needs for rehabilitation technology.
The center is responsible for establishing a comprehensive
statewide network of rehabilitation technology services in the
state. As part of its mission, CRTS will also be a resource for
the southeast region and will disseminate project findings on
rehabilitation technology service delivery activities to
interested individuals.

CRTS will provide information, training and technical assistance
on applications of rehabilitation technology. A primary goal is
to establish effective procedures and methods to make assistive
technology and technology related resources available to
individuals with disabilities in South Carolina.

For more information, please write to the Project Director,
Center for Rehabilitation Technology Services, SC Vocational
Rehabilitation, PO Box 15, West Columbia, SC 29171-0015, or call
1-739-5362.

PUBLICATIONS AVAILABLE

The AMA's Division of Health Science has produced written
guidelines to train physicians to do HIV counseling and HIV blood
test counseling. Entitled, "HIV Blood Test Counseling: AMA
Physician Guidelines," they are $2.00 each for five to 10 copies
(minimum order is five); $1.50 each for 11 to 49 copies; $1.00
each for 50 to 199 copies; and $.75 each for 200 or more copies.
To order, send a check payable to the AMA to the Division of
Health Science, 535 N. Dearborn, Chicago, IL 60610. For more
information, call Dr. Rinaldi at (312) 645-5563.

Hearing impaired children are not identified in the US until an
average age of 2 1/2 years. By contrast, the average age of
identification in Israel and Great Britain is 7 to 9 months. The
Surgeon General of the Public Health Service has set a goal that
by the year 2000, 90 percent of all children with significant
hearing impairments will be identified by 12 months of age. The
SCMA has available an information sheet for parents and a
newspaper column on "Early Identification of Hearing Problems in
Children." For sample copies, contact Kim Fox at SCMA
Headquarters in Columbia. In addition, feel free to use the toll
free Infant and Child Health Hotline (1-800-922-9234) and make
this number available to your patients with small children.

KNOWLEDGE, PERCEIVED RISK, AND BELIEFS
ABOUT AIDS AMONG HIGH SCHOOL AND
COLLEGE STUDENTS IN SOUTH CAROLINA*

FRANCISCO S. SY, M.D., Dr.P.H.**
YVONNE FREEZE-McELWEE, M.S.P.H.
CAROL Z. GARRISON, Ph.D.

KIRBY L. JACKSON, B.A.

Since 1981, the cumulative number of AIDS
cases in the United States has rapidly increased
to 94,280 with 537 of these cases being re-
ported from South Carolina.1’ 2 In the absence
of an effective curative drug or vaccine, the
most important preventive measure available
against AIDS and the transmission of HIV
infection is education aimed at promoting and
facilitating behavior change.3 People who prac-
tice high risk behavior need to be targeted with
strategies tailored for these specific groups.4
The adolescent population is an important
group that requires education since many teens
are sexually active and some will experiment
with intravenous drugs, putting them at high
risk for HIV infection.5 The increasing rate of
teenage pregnancy and sexually transmitted
diseases among adolescents further supports
the idea that adolescents may be at high risk for
HIV infection.5 The fact that less that one
percent of the currently diagnosed total AIDS
cases in the United States are adolescents may
be misleading since AIDS has a long incuba-
tion period.1 Many individuals may acquire
their infection as adolescents but not develop
the clinical manifestations of HIV infection
and AIDS until later in life as adults. The
purpose of this study is to determine the

* From the Department of Epidemiology and Bio-
statistics, School of Public Health, University of South
Carolina, Columbia, S. C. (Drs. Sy and Garrison and
Mr. Jackson); and the South Carolina Department of
Health and Environmental Control, Catawba Health
District, Rock Hill, S. C. (Ms. McElwee). This work was
supported by the Carolina AIDS Research and Educa-
tion (CARE) Project at the University of South
Carolina.

** Address correspondence to Dr. Sy at the Department of
Epidemiology and Biostatistics, School of Public
Health, University of South Carolina, Columbia, S. C.
29208.

knowledge, perceived risk and beliefs about
AIDS among high school and college students
in South Carolina. The results of this study will
be useful to physicians, nurses, health edu-
cators and teachers in developing effective
AIDS education programs for students.

METHODS

A cross-sectional study of high school and
college students in South Carolina was con-
ducted in 1987. The study questionnaire was
originally developed and used with high school
students in San Francisco by DiClemente,
Zorn, and Temoshok.6 Several questions were
slightly modified for use in South Carolina.
Thirty questions pertained to knowledge of
AIDS, while seven questions evaluated the stu-
dents’ perceived risk of acquiring AIDS and
three questions examined beliefs about the se-
riousness of the AIDS epidemic.

The study questionnaire was administered
to students in health and science classes in an
urban public high school. Data from college
students were collected from (1) those attend-
ing a biology seminar on AIDS and sexually
transmitted diseases at an all-male southern
military college and (2) undergraduate stu-
dents enrolled in a physical education class at a
state university. All students present the day
the survey was conducted completed the
questionnaire.

The data were first analyzed using Chi-
square tests to determine if the three educa-
tional groups differed on their response to the
individual questionnaire items. Differences
were also examined by gender. An overall
knowledge score was calculated for each of the
participants as the sum of the responses to
knowledge questions. For each question, cor-

October 1989

481

STUDENTS’ KNOWLEDGE ABOUT AIDS

rect, incorrect, and don’t know responses were
assigned values of 1, —0.5, and 0 respectively.
Mean knowledge scores (possible range — 1 5 to
30) were obtained. To evaluate the students’
perception of risk for acquiring AIDS, a “per-
ceived risk” variable (possible range 0-7) based
on responses to perceived risk questions was
created. Responses indicating a higher per-
ceived risk were assigned a value of 1. Low
perception of risk and don’t know responses
were assigned a value of 0. Similarly, a “se-
riousness” variable (possible range 0-3) was
developed from responses to questions regard-
ing students’ beliefs as to the seriousness of the
AIDS epidemic. Responses indicating serious
concerns were given a value of 1. Not serious
concerns and don’t know responses were given
a value of 0. Analysis of variance was used to
investigate differences in mean knowledge,
perceived risk and seriousness scores by educa-
tional group and gender.

RESULTS

The total study population (N = 345) con-
sisted of 211 high school students and 134
college students. The demographic charac-
teristics of these individuals are shown in
Table 1 . Fifty percent of the study participants
were male, 6 1 % were black, and 6 1 % were high
school students. Age ranged from 13 to 41
years. The high school population was pre-
dominantly black, while the college population

was predominantly white. The military school
population was all male.

The mean knowledge scores for high school,
military college and state university students
were 72%, 86% and 85% respectively. Re-
sponses to selected knowledge questions for
the three groups are shown in Table 2. Signifi-
cantly higher percentages of college students,
both military college and state university stu-
dents, chose correct answers than did high
school students. However, several exceptions
occurred. A higher percentage of high school
students than military college students an-
swered correctly the questions concerning per-
inatal transmission and the high lethality of
AIDS. A higher percentage of college students
(98-100%) than high school students (81-87%)
knew the parenteral routes of HIV transmis-
sion. Likewise, more college students (91-94%)
than high school students (79%) knew that
using condoms can lower the risk of acquiring
HIV infection. Twenty percent of the high
school students believed that AIDS can be
cured if treated early. A significant number
(27-34%) of both high school and college stu-
dents thought that an AIDS vaccine had al-
ready been developed.

Table 3 lists responses to perceived risk
questions. A higher percentage of high school
students (89%) than college students (55-72%)
were afraid of getting AIDS. A high percentage
(61-7 3%) of each of the three groups would take

Table 1. Demographic Characteri sties of Study Participants

by Educational Group

High School Military College State University
N=211 N=44 N=90

% of Sample

61.2

12.8

26.1

Sex: Male

46.9

100.0

33.3

Femal e

53.1

0.0

66.7

Race: Black

94.8

4.5

6.7

White

4.3

93.2

93.3

Other

0.9

2.3

0.0

482

The Journal of the South Carolina Medical Association

STUDENTS’ KNOWLEDGE ABOUT AIDS

Table 2. Responses to Selected Knowledge Questions for Each of the Three Groups

High School Military College State University

True False Don't True False Don't True False Don't

know

AIDS is a medical condition in
which your body cannot fight off
diseases .

70.9

13.1

16.0

97.7

2.3

0.0

85.2

5.7

9.1

AIDS is caused by a virus.

54.8

27.9

17.3

84.1

2.3

13.6

69.0

17.2

13.8

If you kiss someone with AIDS you
will get the disease.

26.2

52.9

21.0

11.6

69.8

18.6

11.1

71.1

17.8

AIDS can be spread by using
someone's personal belongings
like a comb or hairbrush.

9.5

72.4

18.1

0.0

84.1

15.9

1.1

87.8

11.1

Having sex with someone who has
AIDS is one way of getting it.

96.7

2.4

1.0

100.0

0.0

100.0

0.0

If a pregnant woman has AIDS,
there is a chance it may harm
her unborn baby.

91.5

1.9

6.6

90.9

0.0

9.1

93.3

0.0

Most people who get AIDS usually
die from the disease.

91.4

3.3

5.2

86.4

9.1

4.5

90.0

6.7

3.3

Using a condom during sex can
lower the risk of getting AIDS.

79.0

9.0

11.9

90.9

2.3

6.8

94.4

0.0

5.6

You can get AIDS by shaking hands
with someone who has it.

3.8

84.8

11.4

4.5

90.9

4.5

2.2

95.6

2.2

10.

Receiving a blood transfusion
with infected blood can give
a person AIDS.

81.0

7.6

11.4

100.0

0.0

iOO.O

0.0

11.

You can get AIDS by sharing a
needle with a drug user who
has the disease.

86.6

3.8

9.6

97.7

0.0

2.3

97.8

0.0

2.2

12.

AIDS is a life-threatening
disease.

93.3

2.9

3.8

95.5

2.3

100.0

0.0

13.

People with AIDS usually have
lots of other diseases as a
result of AIDS.

31.6

28.2

40.2

90.9

4.5

72.2

6.7

21.1

14.

AIDS can be cured if treated
early.

19.7

40.9

39.4

9.1

72.7

18.2

3.3

77.8

18.9

15.

A new vaccine has recently
been developed for the
treatment of AIDS.

31.9

18.6

49.5

34.1

31.8

26.7

33.3

40.0

a free blood test to see if they had the AIDS
virus if such a free test were available. A few
(4-11%) high school and college students
agreed with the statement, “Living in South
Carolina increases my chances of getting
AIDS.”

Responses to questions concerning students’
belief about the seriousness of the AIDS epi-
demic are presented in Table 4. Most of the
students (80-92%) disagreed with the state-
ment, “AIDS is not as big a problem as the
media suggests.” Fewer college students
(7-18%) than high school students (27%)
claimed that they have heard enough about

AIDS and did not want to hear any more about
it. The majority (90-96%) of the high school
and college students agreed that it is important
that students learn about AIDS in schools.
However only 24% to 37% of both high school
and college students have reported receiving
instruction about AIDS in their school
curricula.

Analysis of variance results and means for
the knowledge, perceived risk, and seriousness
scores by sex and educational group are shown
in Table 5. High school students had the lowest
mean knowledge score and the lowest mean
seriousness score, yet they had the highest

October 1989

483

STUDENTS’ KNOWLEDGE ABOUT AIDS

Table 3. Responses to Perceived Risk Questions for Each of the Three Groups

High School
True False Don't
% know

Military College
True False Don't
% know

State

True

University
False Don't
% know

I am afraid 'of getting AIDS.

89.0

8.1

2.9

72.7

20.5

6.8

55.1

36.0

9.0

Living in South Carolina increases
my chances of getting AIDS.

5.3

61.7

33.0

11.4

54.5

34.1

4.4

73.3

22.2

I am not worried about getting
AIDS.

35.1

61.5

3.4

31.8

65.9

2.3

33.3

54.5

12.2

I am not the kind of person who
is 1 ikely to get AIDS.

57.6

27.1

15.2

68.2

18.2

13.6

82.2

10.0

7.8

I am less likely than most people
to get AIDS.

52.6

26.3

21.1

70.5

9.1

20.5

70.0

10.0

20.0

I'd rather get any other disease
than AIDS.

58.5

24.4

17.1

51.2

20.9

27.9

54.0

10.3

35.6

If a free blood test was available
to see if you have the AIDS
virus, would you take it?

72.7

12.0

15.3

70.5

15.9

13.6

60.9

20.7

18.4

Table 4. Responses to Questions Regarding Beliefs and Availability
in Schools for Each of the Three Groups

of AIDS

Instruction

High School
True False Don't
% know

Military College
True False Don't
% know

State

True

University
False Don't
% know

AIDS is not as big a problem
as the media suggests.

3.3

83.8

12.9

2.3

79.5

18.2

0.0

92.2

7.8

I've heard enough about AIDS and
I don't want to hear any more
about it.

26.8

67.9

5.3

6.8

81.8

11.4

17.8

74.4

7.8

It is important that students
learn about AIDS in school.

93.9

4.3

2.4

95.5

2.3

90.0

6.7

3.3

Have you had any instruction about
AIDS in your school curriculum?

37.1

53.8

9.0

29.5

70.5

0.0

23.6

74.2

2.2

mean perceived risk score. Statistically signifi-
cant differences in the knowledge and per-
ceived risk scores were found between high
school and college students. Knowledge, per-
ceived risk, and seriousness scores did not
differ significantly between the two college
groups. For males, significant differences
existed between high school (X= 19.74) and
college students (military X = 24.9; state
X=24.5) when considering the knowledge var-
iable. Tukey multiple comparison methods
showed that significant differences occurred
both between high school males and military
college males and between high school males
and state university males. For females, signifi-

cant differences occurred between the high
school and college students for both knowledge
(high school X=19.5 vs. college X = 24.7)
and perceived risk (high school X = 3.6 vs,
college X = 2.9).

DISCUSSION

The first published study of students’ knowl-
edge of AIDS was conducted by Price et al. in
1985 among high school juniors and seniors in
four high schools in Toledo, Ohio.7 These in-
vestigators found that, overall, students lacked
sufficient knowledge about AIDS with males
having greater knowledge about AIDS than
females. Additionally, few students (27%) were

484

The Journal of the South Carolina Medical Association

STUDENTS’ KNOWLEDGE ABOUT AIDS

Table 5. Analysis of Variance Results and Means for Knowledge,
Perceived Risk, and Seriousness Variables by Sex
and by Educational Group

High

School

Hilitary
Col 1 ege

State

University

F-val ue

p-val ue

Knowledge:

Males

19.7371

24.9773

24.5167

27.19

0.0001*

Females

19.4682

24.6583

51.17

0.0001*

Perceived Risk:

Hales

3.6495

3.5909

3.3333

0.64

0.5304

Females

3.6422

—

2.9000

13.36

0.0003*

Seriousness:

Hales

2.3814

2.5682

2.2667

1.65

0.1955

Females

2.5299

2.7167

3.22

0.0745

‘Significant at pc. 0005

Note: The military college enrolled only male students.

concerned about contracting AIDS in the study
by Price et al.7 DiClemente et al., in a question-
naire-based study in 1985 among high school
students in San Francisco,6 found that high
school students possessed some knowledge
about AIDS but there was a marked variation
in the level of knowledge regarding major
important items, particularly about preventive
measures during sexual intercourse. Addi-
tional studies on college students and adoles-
cent populations have been conducted by
McDermott et al. and Strunin and HingsonA 9
McDermott et al. found a high level of overall
knowledge about AIDS among university stu-
dents in midwestem United States in 1986.
However 37.3% of the students in their study
did not realize the high lethality of AIDS and
31.7% did not associate acquiring HIV infec-
tion with indiscriminate sexual behavior.8
Strunin and Hingson conducted a random tele-
phone survey of adolescents in Massachusetts
in 1986.9 Their results showed that many ado-
lescents have low level of knowledge about
AIDS, particularly its modes of transmission.
Only 15% reported changing their sexual be-
havior because of fear of acquiring HIV infec-
tion. Furthermore, only 20% of those who
claimed to have changed their behavior were
using effective preventive measures.9

Our study in South Carolina showed that
both high school and college students are in-
formed about AIDS, with college students hav-
ing more knowledge about AIDS than high

school students. Our findings indicate that in-
formation is lacking among high school stu-
dents in some specific aspects of AIDS, such as
the cause, modes of transmission, treatment
and prevention of AIDS. A significant number
of the students thought that a vaccine had been
developed. Differences in mean knowledge
scores among the groups are significant when
comparing high school to college students. The
fact that college students are older may help to
explain this difference. Greater access to
knowledge, specifically scientific journals, spe-
cial lectures and seminars, and increased
awareness of current issues may play a role in
college students having higher knowledge
scores. The military college students may have
had the highest mean knowledge score due to
increased interest in sexually transmitted dis-
eases and AIDS, as evidenced by their volun-
tarily attending a seminar on these topics. High
school students, meanwhile, had higher per-
ceived risks of AIDS. Having little knowledge
of a disease may lead to increased apprehen-
sion. According to Slovic et al., “discussion of
a low-probability hazard may increase its
memorability and imaginability and hence its
perceived riskiness, regardless of what the evi-
dence indicates.”10

Contrary to the findings of Price et al.,7 who
reported greater knowledge among male than
female high school students, our findings sug-
gest that knowledge, perceived risk, and beliefs
do not vary significantly between the sexes.
Our study confirms the observation by DiCle-
mente et al. regarding the relationship between
the level of perceived risk and proximity of
residence to a high AIDS incidence area. A
higher number of students (42%) in the study
by DiClemente et al. believed that living in San
Francisco increases their chances of getting
AIDS.6 Since South Carolina is a low AIDS
incidence state, only 4-1 1% of students in our
study perceived that living in South Carolina
increases their risk of acquiring HIV infection.

In general, the results of our study show a
fairly high level of knowledge in South Caro-
lina about AIDS, with college students having
greater knowledge than high school students.
Yet, because the study population was not
evenly distributed among the races (i.e., the
high school sample was predominantly black
and the college samples were predominantly

October 1989

485

STUDENTS’ KNOWLEDGE ABOUT AIDS

white), it cannot be assumed that differences
are solely attributable to the level of education.
It should be noted that among the state univer-
sity population, blacks did not differ signifi-
cantly from whites when comparing mean
knowledge, perceived risk, and seriousness
scores. However, the socioeconomic status of
black college students may be more similar to
white college students than to the black high
school students.

The low level of knowledge about AIDS
among high school students and their higher
perceived risk underscore the need for school-
based AIDS education programs. Although a
great majority of the students (90-94%) in our
study agreed that AIDS education should be
provided by the schools, only 24-37% of the
students actually reported receiving instruc-
tions about AIDS in their schools. This finding
is consistent with the results of the National
Adolescent Student Health Survey, conducted
in 1987, which found that 35% of the students
in its survey reported receiving instruction on
AIDS in schools.11 The National Academy of
Science endorses school-based AIDS educa-
tion and recommends that education should
be started at a young age with age-specific and
age-appropriate factual and practical contents
and messages.3 The National Research Coun-
cil further recommends that clear and explicit
information on AIDS and sex education be
given to both male and female students.12 Fur-
thermore AIDS education should not only pro-
vide knowledge but also emphasize develop-
ment of specific skills which will help students
adopt and maintain risk prevention behaviors.
In addition, evaluation should be an essential
part of an effective AIDS education program.4
The Centers for Disease Control recently de-
veloped guidelines to help schools plan, imple-
ment and evaluate their AIDS education
efforts. They recommended that the content
of school-based AIDS education programs
should be developed with active participation
of school personnel and parents.13

Physicians play a very vital role in the cur-
rent AIDs epidemic not only in managing the
complex clinical problems of AIDS patients,
but also in AIDS education and prevention
efforts. Physicians should get involved in
school-based AIDS education programs by of-
fering their expertise in developing clear, cul-

turally sensitive and age-appropriate course
content and by regularly presenting accurate
and up-to-date medical information to stu-
dents, school personnels and parents to supple-
ment the school program.4’ 14 The American
Medical Association recommends that “physi-
cians must assume a leadership role in this
effort which will involve drug and sex educa-
tion in schools.”15

Further research is needed in several areas.
Since racial differences could not really be ad-
dressed in this study, studies focusing on
knowledge, attitudes, and beliefs about AIDS
in different racial and ethnic groups need to be
performed. Specifically, studies among black
college students would be particularly useful
since there is a higher proportion of AIDS cases
reported among blacks in South Carolina.2 Ad-
ditionally, studies among students in rural
areas and among younger children, perhaps at
the middle or junior high school level, need to
be conducted.

SUMMARY

Our study reveals that high school and col-
lege students in South Carolina have a fairly
high level of knowledge about AIDS. High
school students have lower level of knowledge
about AIDS than college students. High school
students also have higher perception of risk of
acquiring HIV infection and do not consider
the AIDS epidemic as a very serious health
threat. School-based AIDS education is criti-
cally needed to increase students’ knowledge
about AIDS and to develop skills which will
help them adopt and maintain risk prevention
behaviors. Physicians play a very important
role in developing effective school-based AIDS
education and prevention programs. □

REFERENCES

1. Centers for Disease Control: HIV/AIDS Surveillance
Report, 1-14, May 1989.

2. South Carolina Department of Health & Environmen-
tal Control: HIV/AIDS Surveillance Report, 1-5, April
1989.

3. National Academy of Sciences: Confronting AIDS-
Update 1988. Washington, D. C., National Academy
Press, 1988, p. 64.

4. Sy FS, Richter DL, Copello AG. Innovative Educa-
tional Strategies and Recommendations for AIDS Pre-
vention and Control. AIDS Education & Prevention
1:53-56, 1989.

5. DiClemente RJ. Prevention of HIV Infection among
Adolescents: The interplay of health education and
public policy in the development and implementation

486

The Journal of the South Carolina Medical Association

of school-based AIDS education programs. AIDS Edu-
cation & Prevention 1:70-78, 1989.

6. DiClemente RJ, Zorn J, Temoshok L: Adolescents
and AIDS: A survey of knowledge, attitudes and be-
liefs about AIDS in San Francisco. Am J Public Health
76: 1443-1445, 1986.

7. Price JH, Desmond S, Kukulka G: High school stu-
dents’ perceptions and misperceptions of AIDS. J Sch
Health 55:107-109, 1985.

8. McDermot RJ, Hawkins MJ, Moore JR, Cettadeno
SK. AIDS awareness and information sources among
selected university students. J Am College Health
35:222-226, 1987.

9. Strunin L, Hingson R. AIDS and Adolescents: Knowl-
edge, Beliefs, Attitudes & Behaviors. Pediatrics
79:825-828, 1987.

10. Slovic P, Fischhoff B, Lichtenstein S: Facts vs. fear:
Understanding Perceived Risk. In D Kahneman P
Slovic, A Tversky (Eds.), Judgement Under Uncer-
tainty. New York, Cambridge Press, 1982, p. 465.

11. Centers for Disease Control: Results from the Na-
tional Adolescent Student Health Survey. MMWR
38:147-150, 1989.

12. National Research Council: AIDS, Sexual Behavior &
Intravenous Drug Use. Washington, D. C., National
Academy Press, 1989, p. 19-21.

13. Centers for Disease Control: Guidelines for Effective
School Health Education to Prevent the Spread of
AIDS. MMWR 37(Suppl l):l-9, 1988.

14. National School Boards Association: Reducing the
Risk — A School Leader’s Guide to AIDS Education.
Alexandria, NSBA, 1989, p. 25.

15. Phair JP, Rapoza NP: The Challenge of AIDS for
Physicians Today. In American Medical Association,
AMA Monographs on AIDS. Chicago, AMA, 1987, p.
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4. A. Morales et al, The Journal of Urology 128:
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Editorials

TICK DISTRIBUTION IN SOUTH CAROLINA

Lyme disease has received unprecedented
publicity, primarily in the lay press. Much of
the discussion centers around the tick vector of
this disease. Physicians are receiving many in-
quiries from concerned individuals with re-
spect to possible exposure or infection with the
causative agent, Borrelia burgdorferi. The re-
cent paper by Schuman and Caldwell2 describ-
ing their findings from a survey for Lyme
disease in South Carolina prompted this re-
port. I have been derelict in not sharing this
information sooner.

Because South Carolina was one of the five
leading states with cases of Rocky Mountain
spotted fever (RMSF), in 1973 the Bureau of
Laboratories began to examine ticks for evi-
dence of Rickettsia rickettsii. There were two
primary conclusions from the study; ticks are
found throughout the year and about four per-
cent harbor R. rickettsii.

Although this investigation was directed to-
wards RMSF, it is fortuitous that data on the
distribution of tick species are available and
useful to determine the extent of the putative
vector of the emerging specter of Lyme disease.
During the years 1977 to 1984, 20,498 ticks
removed from human beings were examined.

From our studies it was determined that five
species of ticks were common in South Caro-
lina. They were Dermacentor variabilis, Am-
blyomma americanum, Amblyomma mac-
ulatum, Rhipicephalus sanguineus, and Ixodes
scapularis. The frequency of recovery from
human beings is D. variabilis, 92.4%; A. ameri-
canum, 5.1%; R. sanguineus, 1.6%; A macula-
turn, .6% and I. scapularis .3%.

D. variabilis and A. americanum are essen-
tially summer ticks in South Carolina. The
former was found from March until November
and the latter was active from March through
September. R. sanguineus and A. maculatum

were found essentially throughout the year. I.
scapularis, on the other hand, is a winter tick in
South Carolina. It was found from December
through April but appeared earlier in the
Winter (October and November) in the coastal
counties.

The vectors of Lyme disease unquestionably
appear to be I. dammini in the northeast and
north-midwestern United States and I. pacif-
icus in the western United States. I. scapularis
is widespread throughout the southern states.
Although there have not been sufficient studies
on the vector of Lyme disease in the southeast
United States, evidence has been presented
that I. dammini and I. scapularis are the same
species.

Although few in number (66 ticks), /.
scapularis was found in 25 of the 46 counties
from border to border. Forty-four ticks were
from the coastal counties, 1 1 from the sandhill
counties, and 1 1 from the Piedmont counties.

An earlier report of ticks and RMSF from
this laboratory was published in 1 978. 1 That
work covered the time period from 1974-76.
During those years, 6,76 1 ticks were examined.
The geographical and species distribution of
the five species were similar to the findings
reported here.

A detailed analysis of the tick distribution,
by species, prevalence if rickettsial infection,
temporal and geographic distribution is in pre-
paration.

Arthur F. DiSalvo, M.D.

Chief

Bureau of Laboratories

South Carolina Department
of Health and
Environmental Control

Box 2202

Columbia, S. C. 29202

494

The Journal of the South Carolina Medical Association

REFERENCES

1. Loving S M, Smith A B, DiSalvo A F, Burgdorfer W:
Distribution and Prevalence of spotted fever group
Rickettsiae in Ticks from South Carolina, with an epi-
demiological survey of persons bitten by infected ticks.
AM.J.Trop.Med.Hyg. 27:1255-1260, 1978.

2. Schuman S H, Caldwell S T : Lyme and other tick-borne
diseases acquired in South Carolina in 1 988: A survey of
1,331 physicians. J.S.C. Med.Assoc. 85:311-314, 1989.

LETTER TO THE EDITOR

The following poem was submitted by a can-
cer victim who now does volunteer work with
cancer patients in her area’s hospitals.

— CSB

CANCER WARD

A Pied Piper on Rounds, he pontificates
in his untouchable white smugness
of doctoring to his mesmerized students
and patients alike.

Diseased bodies silence their agonies,
praying to find a speck of hope
against all hope

within the manicured charade each day.
Impatiently, they wait in awe and
expectation —

as children would see the freakshow at the
fair. . . .

But here they are the freaks
With tumors nesting in their flesh
and parasites feeding from within.

The Piper’s pipe grows silent as he leaves.
The Magic is gone.

Until tomorrow.

Ruth Ilg
P. O. Box 2323
Anderson, S. C. 29622

REGIONALIZED PERINATAL
CARE: THE NEXT STEP

The authors of the symposium, “Region-
alized Perinatal Care in South Carolina” in the
August, 1989 issue of The Journal provided a
well-written, comprehensive review of the evo-
lution of such care in our state. The next logical
phase in the evolution of regionalized perinatal
care should be the establishment of multiple,
fully-staffed, and well-equipped Level II Cen-
ters within each region.

While a few of the currently labelled Level II
Centers meet designated standards, most do
not. Fully-operational Level II Centers would
(a) provide appropriate care for many non-
ventilator dependent sick infants — for exam-
ple those with such problems as septicemia and
jaundice; (b) accept recovering and convalesc-
ing infants from Level III Centers; and (c) offer
local convenience for many families.

Such a system of improved Level II Centers
would substantially reduce the growing vol-
ume of sick neonates inundating our Level III
Centers. Obviously, the critical issues to be
addressed are funding and staffing. The former
issue must be addressed by the South Carolina
Department of Health and Environmental
Control.

Our state can be justifiably proud of the
progress made in perinatal care over the past
1 5 years. However, we most certainly have a
great deal more to do. A “fleshing out” of the
Level II Centers would be a major step in this
direction.

C. Warren Derrick, Jr., M.D.
Chairman

Department of Pediatrics
University of South Carolina
School of Medicine
5 Richland Medical Park
Columbia, S. C. 29203

Guest editorials reflect the opinion of the author and do not necessarily reflect the opinion of the
Editorial Board or the leadership of the South Carolina Medical Association.

—CSB

October 1989

495

On the Cover

THOMAS PRIOLEAU WHALEY, M.D., 1870-1918
PRESIDENT, SCMA, 1907

Thomas P. Whaley was born in Pendleton,
S. C., July 12, 1870. He was educated in
Charleston, graduating sixth in his class from
the Medical College of the State of South Caro-
lina in 1892 and thus earning an appointment
as house physician in St. Francis Xavier’s In-
firmary. After his internship, Dr. Whaley spent
some time studying in Vienna and Paris where
he gained valuable experience in surgery,
genito-urinary disease and dermatology.

After returning to Charleston, Dr. Whaley
had a varied and successful practice. He
taught, at different times, both dermatology
and genito-urinary surgery at the Medical Col-
lege, and lectured at the Training School for
Nurses. He was a popular physician and was
“quite dear to his patients.” He is said to have
been one of the first in the area to use spinal
anesthesia and the x-ray machine, to decapsu-
late the kidney, to recognize beri-beri, and to
devote so much attention to urology.

In 1907, the year that Dr. Whaley presided
over the SCMA, the main topic of discussion
seems to have been the action by insurance
companies to reduce the fees paid to physi-
cians for pre-insurance examinations from
$5.00 to $3.00. His presidential address as he
retired from the chair at the annual meeting in
Bennettsville was devoted almost in its en-
tirety to the question of reasonable recom-
pense for doctors’ services:

The profession of medicine is certainly
unique in one sense at least. It would seem
that its chief object is to destroy that which
supplies its nourishment. . . . We have mini-
mized the terrors of smallpox; have almost
banished cholera from the face of the earth;
have shown how the terrible bubonic plague
can be controlled; have perfected a cure for
the dreaded diphtheria; have shown that ty-
phoid fever, tuberculosis, yellow fever and
malarial fever are preventable diseases; and
peritonitis is being rapidly nipped in the
bud.

We have shown that syphilis is not only
preventable but curable; that ophthalmia
neonatorum need never exist; that tetanus is
preventable; and finally that many here-
tofore fatal surgical diseases, including can-
cer, if taken in their incipiency are perfectly
curable. At this rate what is to become of the
doctor? . . . Shall we finally present the as-
tounding spectacle of a profession starving
to death by virtue of its own attainments?

Although Dr. Whaley’s fear of “working
himself out of a job” might have been a bit
premature, his litany of the accomplishments
of the medical profession is impressive.

Betty Newsom

The Waring Historical Library

496

The Journal of the South Carolina Medical Association

LEGISLATIVE REPORT

This year the objectives of the Legislative Committee concern themselves mainly with the grass
roots level. All county chairwomen have received a letter outlining the objectives of the committee.
The objectives are: (1) more effective communication between the auxiliary and the federal and the
state legislative arenas; (2) voter registration; (3) personal contact with state representatives; (4)
personal knowledge of state medical issues (this includes knowing where the SMCA stands on each
issue); (5) educating and informing the county auxiliary members on medical issues being consid-
ered by the state legislature; and (6) use of the phone bank alert.

The county chairwomen were informed that they will be receiving the Legislative Update
whenever it is published. This material will inform them on current bills in the state legislature
concerning health issues. They were also informed to call the SCMA office and to check with
Barbara Whittaker, Staff Director, or Jan McKeller, Director of Health Policy Affairs, concerning
the position of the SCMAA on medical matters. In June of this year, these chairwomen were also
encouraged to speak out against the Expenditure Targets issue. They were also encouraged to
increase participation in SOCPAC this year.

Aside from encouraging communication among county legislative chairwomen, plans are being
made for auxiliary members to become more active in the political arena by inviting Senator Nell
Smith from Pickens County to speak at the Fall Board meeting this month. Hopefully, this will
inspire all of us to be more aware of the medical issues facing our state of South Carolina. Also at the
Winter Workshop in January, the Legislative Committee would like to invite several members of
the Medical Affairs Committee of the House and Senate to join us in Columbia for lunch. These
plans have been discussed with Jan McKeller, but have not been firmed up yet.

As one can tell, our objectives are many. Hopefully, the legislative committee can reach our goals
through effective communication and hard work. When we, as the SCMAA, become more
politically aware and more politically active, we will begin to improve the medical atmosphere in
the state of South Carolina.

Rosemary M. Cook
Legislative Chairman

Jeanne Sabback
Co-Chairman

October 1989

497

PHYSICIAN: The VA Medical Center has an
opening in the Alcohol and Drug Treatment
Unit beginning October, 1989. Applicants
should be U.S. citizens with board certification
or eligibility in Psychiatry, Family Practice, or
Internal Medicine. The position involves a fac-
ulty appointment at the Medical University of
South Carolina and participation in patient
care, teaching, and an active on-going research
program. Send CV and names of three refer-
ences to: James D. Sexauer, M.D., VAMC, 109
Bee Street, Charleston, SC 29403, (803)
577-5011, ext. 7234. EOE.

VACANCY ANNOUNCEMENT: STAFF
PHYSICIAN, WHITTEN CENTER, a pro-
gressive ICF Institution serving the mentally
retarded in the Piedmont Region of SC has an
immediate need to fill a STAFF PHYSICIAN
position.^ Must be able to obtain SC medical
license. Excellent SC benefit program to in-
clude annual, sick and family sick leave, health
and dental plans, life and term insurance, de-
ferred comp and retirement. Send complete
resume to Fred Robinson, M.D., Whitten Cen-
ter, P.O. Box 239, Clinton, SC 29325 or call
(803) 833-2733, Ext. 334.

1990 CME CRUISE/CONFERENCE ON
MEDICOLEGAL ISSUES AND SELECT-
ED MEDICAL TOPICS— Caribbean, Ber-
muda, Alaska/Canada, New England, Scandi-
navia, W. Mediterranean, Europe, Asia, Trans
Panama Canal. Approved for 20-28 CME Cat-
egory 1 Credits (AMA/PRA) and AAFP pre-
scribed credits. Distinguished lecturers.
Excellent group fares on finest ships. Pre-
scheduled in compliance with IRS require-
ments. Information: International Confer-
ences, 1290 Weston Road, Suite 316, Ft.
Lauderdale, EL 33326. (800) 521-0076 or (305)
384-6656.

INDEX TO ADVERTISERS

Amethyst 468

C&S Bank 493

Charter Rivers Hospital Cover 2

Hamilton Industries Cover 2

Intrav 458

Eli Lilly & Company 477

Medical Protective Company 491

Medical Software Management, Inc 468

Merck, Sharp & Dohme Cover 3, Cover 4

National Emergency Services 487

Pain Therapy Centers 492

Palisades Pharmaceuticals 487

Pristine Properties 472

Ridgeview Institute 457

Roche Laboratories 453

U.S. Air Force 467

U.S. Army Reserve 488

U.S. Navy Reserve 454

Winchester Surgical Supply Company . . . Cover 2
Winthrop Pharmaceuticals 478, 479, 480

498

The Journal of the South Carolina Medical Association

VOLUME 85

NOVEMBER 1989

NUMBER 11

INTRAVENOUS STREPTOKINASE THERAPY
FOR ACUTE MYOCARDIAL INFARCTION IN
A COMMUNITY HOSPITAL: EFFECT ON
VENTRICULAR FUNCTION AND MORTALITY*

JOSEPH L. TRASK, M.D.

NEIL W. TRASK III, M.D.

WILLIAM J. CUSHING, M.D.

HARVEY E. BUTLER, JR., M.D.

BRUCE W. USHER, M.D.**

Since its approval for intracoronary use by
the FDA, streptokinase, and thrombolytic
therapy, in general, have become accepted
standard therapy in the treatment of acute
myocardial infarction. The reported efficacy
for intravenous streptokinase varies from
3 1 %x to 60%, 2 but in most studies is estimated
at approximately 51%.3 Clinical trials at aca-
demic centers do not always reflect the true
safety and efficacy of a treatment when applied
in a community practice. To evaluate strep-
tokinase’s safety and efficacy in a community
practice, we retrospectively reviewed the rec-
ords of the initial 102 patients treated with
intravenous streptokinase at a nearby commu-
nity hospital. This study, we feel, accurately
reflects the results of streptokinase therapy in a
community medical center.

* From Grand Strand Hospital, Myrtle Beach, S. C. (Drs.
Trask, Trask, Cushing, and Butler) and the Cardiology
Division, Medical University of South Carolina,
Charleston, S. C. (Dr. Usher).

** Address reprint requests and correspondence to: Bruce
W. Usher, M.D., Cardiology Division, Medical Univer-
sity of South Carolina, 171 Ashley Avenue, Charleston,
S.C. 29425-2221.

METHODS

From February 1984 until December 1987,
102 patients were given intravenous strep-
tokinase at the Grand Strand Hospital, Myrtle
Beach, South Carolina. All patients were eval-
uated by a cardiologist prior to initiation of
therapy. The decision as to whether to treat the
patient with streptokinase was initially made
by the referring physician and then later in
conjunction with the consulting cardiologist.
Specific exclusion criteria were not recorded,
but in general were:

1 . Recent (six weeks) surgery.

2. Any history of previous cerebral vascular
accident.

3. Uncontrolled hypertension.

4. Recent history of gastrointestinal bleed-
ing or active ulcer.

5. Previous treatment with streptokinase.

6. Diabetic retinopathy.

The determination as to whether the patient
was having an acute infarction was made by
the referring physician and the consulting car-
diologist. General criteria were:

November 1989

503

INTRAVENOUS STREPTOKINASE

1. Prolonged pain consistent with an isch-
emic origin.

2. EKG changes consistent with an acute
infarction.

In general, EKG changes consisted of ST eleva-
tion in a pattern suggestive of an acute myocar-
dial infarction rather than pericarditis or early
repolarization. One patient had non-specific
ST-T wave changes, a previous history of in-
farction and coronary artery bypass surgery,
and prolonged pain consistent with ischemia.
However, he was excluded from analysis due
to normal cardiac isoenzymes and an inability
to diagnose or localize a region of injury by
electrocardiograms. A second patient had
marked anterior ST depression rather than ST
elevation and prolonged ischemia-type pain.
This patient was included in the total analysis
because of EKG localization of his ischemia
and cardiac isoenzymes consistent with myo-
cardial necrosis.

In all cases, streptokinase was given intra-
venously over 45 to 90 minutes. In most cases,
the drug was infused over approximately one
hour. Most patients (86.1%) received 1.5 mil-
lion units of streptokinase; however, 13
(12.9%) received one million units and one
(0.99%) received 750,000 units. All patients
were premedicated with Solumedrol and Bena-
dryl intravenously. In addition, patients were
treated with intravenous Lidocaine and nitro-
glycerin. Following completion of the strep-
tokinase infusion, all of the patients were
placed on a continuous heparin infusion to
maintain the PTT at approximately 1. 5-2.0
times normal. Patients were given additional
therapy such as beta-blockers, aspirin, and cal-
cium antagonists, at the discretion of the pri-
mary physician and consulting cardiologist.

Of the 101 patients, 89 (88.1%) were referred
for cardiac catheterization and their catheter-
ization reports were reviewed. One patient un-
derwent catheterization elsewhere, and his
report could not be obtained. Eleven patients
did not undergo cardiac catheterization. Seven
of these patients were treated medically, three
patients died in the early hospital course, and
one patient was discharged against medical
advice prior to completion of his evaluation.

RESULTS

The average age of the patients was 55.2

TABLE 1

Mean Left Ventricular Ejection Fraction
Post Intravenous Streptokinase

Patent Vessel

Occluded Vessel

All patients

56.6%

43.4% (p<0.001)

— Anterior infarction

55.8%

37.9% (p<0.001)

— Inferior infarction

57.5%

49.0% (pcO.001)

years, with a range of 29 to 77 years. As would
be expected, there was a male predominance
with 80 (79.2%) males and 21 (20.8%) females
(Table 1). Infarct distribution was surprisingly
even with 51 anterior infarctions and 50 in-
ferior infarctions. Patients were evaluated and
treated with streptokinase relatively quickly.
Twenty-one (20.8%) patients began receiving
streptokinase within 1.5 hours after onset of
symptoms. Fifty-three (52.5%) patients had in-
itiation of therapy within 1.5 to 3.0 hours after
onset of symptoms, and 27 (26.7%) began ther-
apy greater than 3.0 hours after onset of symp-
toms (Figure 1). With the exception of three
patients whose therapy was started at 6.25, 7.0,
and 9.0 hours after onset of symptoms, all
other patients began therapy in less than six
hours from onset of symptoms. Overall, 73.3%
of our patients began therapy within 3.0 hours.

As previously noted, 89 (88. 1%) patients un-
derwent cardiac catheterization after receiving
streptokinase, and their results were reviewed.
The average delay from initiation of therapy to
cardiac catheterization was 3.89 days, with a
range of one to 31 days. Sixty-one (68.2%) of
our patients underwent cardiac catheterization

FIGURE 1. Time from onset of symptoms to institution of
intravenous streptokinase.

504

The Journal of the South Carolina Medical Association

INTRAVENOUS STREPTOKINASE

within 72 hours and 18 (20%) patients within
24 hours. Almost 90% (80 patients) were stud-
ied within the first week after therapy.

Complications were reviewed in all patients
up to the time of their discharge. Only three
patients died during their hospitalization, for
an overall mortality of 2.97%. All deaths were
associated with anterior infarctions and dra-
matic, extensive EKG changes. Two patients
died within 24 hours with refractory con-
gestive heart failure and cardiogenic shock.
The third patient died five days post-infarction
secondary to myocardial rupture. No death
was directly attributable to thrombolytic ther-
apy. Seven patients (6.93%) had excessive
bleeding recorded from any site, and four pa-
tients (3.96%) required blood transfusions.
The most serious episode of bleeding was sec-
ondary to inadvertent puncture of a carotid
artery during central line placement. Sixteen
patients (15.8%) had recurrent chest pain after
streptokinase therapy and one patient (0.99%)
had a documented re-infarction.

At cardiac catheterization, the predicted
infarct-related vessel was patent in 65 (73%) of
the patients and occluded in 24 (27%) patients.
Of those patients treated within the first 1.5
hours after onset of symptoms, 85% of the
predicted infarct-related vessels were patent.
When therapy was instituted between 1.5 and
3.0 hours after onset of symptoms, the patency
rate was 72%, and patients treated after 3.0
hours had a 65% patency rate (Figure 2). In
addition to coronary artery patency, left ven-
tricular ejection fractions were assessed in 84
(94%) of the patients undergoing cardiac cathe-

Vessel Patency
Post IV Streptokina:

FIGURE 2. Angiographic patency rate of predicted
infarct-related coronary7 artery.

FIGURE 3. Extent of angiographic determined coronary-
artery disease.

terization. The majority of the ejection frac-
tions were obtained by ventriculography at the
time of catheterization, although some pa-
tients were assessed by 2-D echocardiography
or radionuclide angiography. In the 64 patients
with patent vessels, the mean ejection fraction
was 56.6%. This was significantly (p<.001)
greater than the mean ejection fraction of
43.4% in the 20 patients with occluded vessels.
In patients with anterior infarctions, the mean
ejection fraction was significantly higher,
55.8% vs. 37.9% (p<0.001), in those patients
with patent vessels as compared with patients
with occluded vessels. As has been reported in
other studies, the statistical difference in mean
ejection fractions for inferior infarctions with
patent vessels (57.5%) vs. those with occluded
vessels (49%) was not highly significant

(p<0.01).

Coronary arteriograms revealed that 33
(37.1%) of the patients undergoing cardiac
catheterization had single-vessel disease.
Thirty-one (34.8%) patients had significant
two-vessel disease, and 25 (28. 1%) patients had
three-vessel disease (Figure 3). Significant ste-
nosis was defined as 50% luminal narrowing in
one of the three main coronary arteries or their
branches. Thirty-four patients (33.7%) were
treated with medical therapy after receiving
streptokinase while 33 patients (32.7%) under-
went coronary angioplasty alone, and 28
(27.7%) underwent coronary artery bypass
grafting. Three patients (2.97%) underwent
both angioplasty and bypass surgery.

DISCUSSION

This study documents the influence of intra-

November 1989

505

INTRAVENOUS STREPTOKINASE

venous streptokinase therapy on community
hospital treatment of myocardial infarctions.
In this study, patency rates were high in the
entire treatment group and especially in those
patients treated within 1.5 hours after onset of
symptoms. Certainly, some of the patent ar-
teries were not opened as a result of strep-
tokinase, but represent spontaneous clot lysis
or recanalization which has been demon-
strated to occur in some patients as part of the
natural history of myocardial infarctions.4
Spontaneous recanalization occurs with in-
creasing frequency in the initial two weeks
after infarction, but infrequently in the initial
three to four hours after occlusion, when it
would be beneficial.5' 6 Therefore, the improve-
ment in ventricular function seen in this study
cannot be explained on the basis of spon-
taneous recanalization. Patients who did not
have reperfusion with streptokinase therapy,
but who later had spontaneous clot lysis, were
included in the patent groups. These patients
would be expected to have lower ejection frac-
tions and, therefore, cause the study to under-
estimate the true improvement in ejection
fraction. In addition, some patients had pre-
vious infarctions which depressed their ejec-
tion fractions, and their inclusion would result
in further underestimation of benefit.

Most importantly demonstrated in this
study was the reduction in mortality. This was
not a controlled study and, therefore, no defi-
nite comparisons can be made. However, the
reported mortality is 10% in patients hospi-
talized with acute myocardial infarction and
treated with standard therapy.7 Certainly, our
mortality of 2.97% is very low and represents a
70% reduction in expected mortality. In light
of the relatively few complications, the risk-
benefit ratio of giving streptokinase therapy in
the setting of acute myocardial infarction is
very low.

SUMMARY

Streptokinase can dramatically impact upon
management of myocardial infarctions in
community hospitals. When given by experi-
enced personnel during the first six hours after
onset of symptoms, streptokinase is associated
with a high patency rate, improved left ven-
tricular function, and reduced mortality. Care-
ful screening of patients results in a low
complication rate with infrequent serious
bleeding. Streptokinase should be utilized in
those hospitals without cardiac catheterization
facilities, but in light of the relatively high
incidence of recurrent pain ( 1 5.8%), transfer of
stable patients to a facility with a catheteriza-
tion laboratory should be carried out within 24
to 72 hours. As approximately 60% of patients
will require PTCA, CABG, or both, diagnostic
cardiac catheterization should be considered
in all patients unless there are other mitigating
factors. □

REFERENCES

1 . Chesebro JH, Knatterud G, et al: Thrombolysis in Myo-
cardial Infarction (TIMI) Trial, Phase I: A comparison
between intravenous tissue plasminogen activator and
intravenous streptokinase. Circulation 76:142-154,
1987.

2. Ganz W, Geft I, et al: Intravenous streptokinase in
evolving acute myocardial infarction. Am J Cardiol
53:1209-1216, 1984.

3. Spann JF, Sherry S: Coronary thrombolysis for evolv-
ing myocardial infarction. Drugs 28:465-483, 1984.

4. DeWood MA, Spores J, et al: Prevalence of total coro-
nary occlusion during the early hours of transmural
myocardial infarction. N Engl J Med 303:897-902,
1980.

5. Kennedy JW, Ritchie JL, Davis KB, Fritz JK: Western
Washington randomized trial of intracoronary strep-
tokinase in acute myocardial infarction. N Engl J Med
309:1477-1482, 1983.

6. Khaja F, Walton JA Jr, et al: Intracoronary fibrinolytic
therapy in acute myocardial infarction. Report of a
prospective randomized trial. N Engl J Med
308:1305-1311, 1983.

7. Pasternak RC, Braunwald E, Sobel BE: Acute myocar-
dial infarction. Heart Disease. A Textbook of Car-
diovascular Medicine. Braunwald E (ed). Philadelphia,
WB Saunders Co, 3rd Ed, 1988, p 1222.

506

The Journal of the South Carolina Medical Association

SCHIZOPHRENIA: PROMISING NEW
DIRECTIONS IN SOUTH CAROLINA*

ALBERTO B. SANTOS, JR., M.D.**
PAUL A. DECI, M.D.

The care of patients with schizophrenia con-
tinues to be one of medicine’s greatest chal-
lenges. The schizophrenic symptoms most
familiar to us as physicians are the bizarre
belief systems (delusions) and the false percep-
tions (hallucinations), typically of a command-
ing or derogatory nature. These dramatic
symptoms, known as the “positive” symptoms
of schizophrenia,1 are usually ameliorated by
antipsychotic medications. Other aspects of
the illness, the so-called “deficit” or “negative”
symptoms, are not as responsive to medica-
tions. Negative symptoms include social with-
drawal, decreased motivation and goal-
directed behavior, and emotional blunting
such that one does not seem “in tune” with
social and cultural trends. It is these negative
symptoms, not generally responsive to medi-
cations, which are most destructive to social
and occupational functioning and pose the
greatest challenge for our profession.

Schizophrenia has traditionally been consid-
ered a chronic, progressive illness with a course
marked by exacerbations and remissions. We
see many patients who experience acute epi-
sodes of altered mentation with hallucinations
and/or delusions who respond to medications,
are able to recover fully, and never have a
subsequent episode. Such brief psychotic syn-
dromes are not representative of schizo-
phrenia. Instead, an acute psychotic episode in
schizophrenia is followed by significant deteri-
oration in social and occupational functioning.
For some, particularly those who respond
poorly to medication, the course can be devas-
tating with deterioration to a level where
custodial care is necessary. For most, however,

* From the Department of Psychiatry and Behavioral
Sciences, Medical University of South Carolina,
Charleston, S. C.

** Address correspondence to Dr. Santos at the Depart-
ment of Psychiatry and Behavioral Sciences, Medical
University of South Carolina, 171 Ashley Avenue,
Charleston, S. C. 29425-2221.

there is a chronic-intermittent course where
symptom recurrence can be anticipated and
incorporated into their treatment plan. We
now believe that for many patients the pro-
gressive nature of the illness can be altered
through a combination of pharmacologic and
environmental interventions.

SERVICES TO PATIENTS
WITH SCHIZOPHRENIA

Before the introduction of antipsychotic
medications, South Carolina followed national
trends providing life-long institutional care for
persons with schizophrenia and other severely
disabling psychiatric disorders. Such care was
centralized in Columbia at the South Carolina
State Hospital on Bull Street.

It has been suggested that institutional care
promotes morbidity.2 The nature of custodial
care does not allow for nor encourage decision
making. Such choiceless existence may further
atrophy the capacity of the mentally ill to nego-
tiate the everyday challenges of life and to
conform to ordinary cultural demands.

The utilization of antipsychotic medications
which allowed patients to be discharged her-
alded a national movement away from institu-
tionalization and towards community-based
services. Yet, many patients are rehospitalized
frequently for the following reasons:3'5

• only 25% of discharged patients actually
keep their outpatient appointments;

• medication compliance rates for the first
month are 50% at best;

• of medication compliant patients, only
one in five is prescribed adequate doses;
and

• despite optimal medication, there is a 50%
relapse rate in the first 12 months.

Federally funded mental health centers
which were set up across the state and nation,
in part to help with the rehabilitation of de-
institutionalized patients, did not uniformly

November 1989

509

SCHIZOPHRENIA

provide sufficient community support services
nor family and public education nor outreach
services to insure medication compliance and
facilitate community integration. Hence, men-
tal health centers have been criticized for run-
ning outpatient clinics for more compliant
patients, and thus, in effect, discriminating
against individuals with chronic mental ill-
nesses such as schizophrenia. Such criticisms
are perhaps unwarranted since the federal gov-
ernment failed to make this goal clear and
worse, the reports of federal evaluative site
visits were ignored.4

The failure of deinstitutionalization can be
summarized as follows: Medication, which
held the greatest promise for deinstitution-
alization, was only effective in half the patients
since it did not ameliorate negative symptoms
and compliance rates were less than expected.
No other service system options were suffi-
ciently explored or researched in order to pro-
vide guidance to clinicians in the community
for the care of deinstitutionalized patients who
were expected to conform to the ground rules
of office-based practice. Philosophically, we
overemphasized mental health instead of men-
tal illness and set up an outpatient system
which targeted those who sought help them-
selves, something not characteristic of an indi-
vidual with schizophrenia.

NEW APPROACHES—

NEW SOLUTIONS

There exists a growing body of evidence
which suggests the presence of specific neu-
ropathologic abnormalities in schizophre-
nia.6'9 Current thinking suggests that a fixed
pathophysiological insult early in a patient’s
development interacts with normal brain de-
velopment producing overt pathology later in
life.9 These findings have led professionals to
utilize a rehabilitation model for the treatment
of patients with schizophrenia. That is, these
patients can benefit most from a combination
of symptomatic relief through the use of medi-
cations and environmental manipulations to
help the patients adapt to their handicaps.

A number of innovative approaches have
received considerable attention in the recent
literature. Significantly lowered rates of hospi-
talization have been reported for those treated
with a combination of medications and re-

habilitative interventions which teach symp-
tom management and other skills to patients.
Education is provided for family and friends
about the illness, medications, and symptom
management which enhances their ability to
help compensate for the patient’s cognitive
deficits.5’ 10 Interventions are aimed at reduc-
ing vulnerability and adding to the clinical
efficacy of medications. These approaches in-
volve the family as allies with the physician in
contrast to earlier traditions in which the fam-
ily was subtly considered responsible for the
patient’s condition and often treated adversely.

As service delivery models are developed to
address this very serious public health prob-
lem, one particular approach has received
considerable attention in the scientific liter-
ature.11- 12 This approach was developed in
Madison, Wisconsin in the early 1970s. A
group of state hospital professionals, recogniz-
ing that patients were not generally capable of
navigating the maze of mental health outpa-
tient resources, set up an aftercare system that
allowed the clinician to follow the patients
wherever and whenever it was deemed neces-
sary. Both the discontinuity of care from inpa-
tient to outpatient setting and the missed
appointment obstacles were thus eliminated.

The approach, now called Programs for As-
sertive Community Treatment (PACT) or the
Training in Community Living (TCL) Model,
is used statewide in Wisconsin and in some 36
other cities in 15 states across North America
and in Australia.13 This service delivery model
insures that all patients are monitored for the
appropriate doses of medications. All friends,
family, and other interested individuals in a
patient’s support network are informed of the
patient’s handicaps and unique needs.

PROGRAM DESCRIPTION

The principal form of treatment is the use of
a 24-hour, 7 day/week, interdisciplinary ser-
vice team which meets daily to refine its treat-
ment plans. The total range of community-
support interventions is made available
through this team to a maximum case load of
120 patients per program. Overall goals are to
maximize medication compliance, residential
stability, and productive activity. Services are
delivered through assertive outreach (field
work) in the community. The multidisciplin-

510

The Journal of the South Carolina Medical Association

SCHIZOPHRENIA

ary team is screened both for competency in
their area of expertise (psychiatry, nursing, so-
cial work, vocational and social rehabilitation)
and for dedication to the mission of the pro-
gram. Frequency and nature of contact are
determined by the individual needs of the pa-
tient. This includes frequent home visits to
assess compliance with medications and the
patient’s living conditions. Each patient lives
in as normalized an environment as possible.
Although the living situation must promote
stability, alternatives include living on their
own, with a roommate, in a group setting, or
with family. If necessary, the team will serve as
an intermediary between a patient and a land-
lord. Meaningful work is obtained for indi-
viduals desiring and capable of employment.
The staff compensates for each patient’s emo-
tional and cognitive deficits while serving as
“work coaches” for those needing assistance.
The team provides continuity of care across all
areas of need. The care is highly individualized
and continues for as long as the patient resides
in the team’s catchment area.

Differences between traditional outpatient
treatments and Programs for Assertive Com-
munity Treatment are listed in Table 1. While
eligibility criteria will vary slightly among
sites, the teams serve adults (ages 18-65) with
schizophrenia or other chronic psychotic dis-
orders with a history of multiple or long-term
psychiatric hospitalizations and who require
assertive outreach to follow through with pre-

scribed treatments and to learn to live in the
community.

CONTROLLED RESEARCH ON PACT

There is strong empirical support for the
effectiveness of the PACT model in markedly
reducing patient time in psychiatric hospi-
tals. Evidence comes from controlled studies
in Madison, WI and from controlled evalua-
tions of replications/adaptations in other
settings.14'24

The initial Madison project randomly as-
signed patients who were about to be hospi-
talized (excluded patients with severe organic
brain syndrome, mental retardation or pri-
mary alcoholism) to either the PACT program
or to a control group which received short term
in-hospital treatment followed by traditional
aftercare in the county system. Patients in the
PACT group spent significantly less time in
psychiatric hospitals than the control patients.
The PACT group patients spent significantly
more time than the controls in independent
living situations and demonstrated signifi-
cantly more favorable community adjustment
in the areas of employment, social relation-
ships, symptomatology, and satisfaction with
their lives. A comprehensive economic bene-
fit-cost study comparing PACT with the tradi-
tional county system revealed a small overall
economic advantage in favor of the PACT
model.14 A study of the relative “social costs”
of PACT versus the traditional model revealed

TABLE 1

Differences Between Traditional Outpatient Care and Programs for Assertive Community Treatment

Traditional Outpatient Care

Programs for Assertive Community Treatment

Treatment Site

In the clinic

In the community

Treatment

Focused (psychotherapy, medication)

Total care

Provider

Individual clinician

Team

Staffing

1:50 clinical staff to patient ratio

1:12 clinical staff to patient ratio

Staff Availability

Working office hours

Team available 24 hours/day, 7 days/week

Frequency of Contact

Once every 2 weeks in most cases

Daily in most cases

Family Contact

Occasional

Weekly in most cases

Patient Medication

Responsibility of patient and family

Responsibility of staff, can be

Housing Arrangements

Responsibility of patient and family

administered daily by staff if needed
Responsibility of staff

Case Management Function

usually

Broker of service

Service provider

Expectations

Gradual approach from total dependence

Maximize independence from beginning,

to independent living

drop back if necessary

November 1989

511

SCHIZOPHRENIA

that the significant gains made by the PACT
patients were not at the expense of additional
burden to family or community members.15
The project lasted two years after which the
PACT patients were discharged to traditional
MHC care. Most of the benefits gained were
lost upon discontinuation of the inter-
vention.12

The Madison-based research group are cur-
rently implementing a 12-year prospective
controlled study involving only young adult
patients with clearly defined schizophrenia or
schizophrenic related disorders.16 Patients in
this project are treated in an ongoing rather
than time-limited fashion such that by the end
of the project patients will have been treated
and assessed in an ongoing manner for be-
tween five and 12 years. The control group
consists of state-of-the-art services including
mobile crisis teams, psychosocial clubhouses,
special living arrangements and assertive out-
reach to patients who drop out of treatment.
Findings from the first two years’ data analysis
indicate that the PACT model is again remark-
ably effective at reducing time spent in institu-
tions.17 PACT was effective in both reducing
hospitalizations and returning patients to. the
community rapidly after an acute episode. The
low time spent by PACT patients in institu-
tional settings was not offset by time spent in
jails/penal settings or in homelessness or
homeless shelters. With reference to housing,
the greatest proportion of PACT patients
(73.6%) were living in low supervision settings,
primarily independent apartments, while the
largest proportion of control patients (53.66%)
were living in “high supervision” settings.17

Several controlled studies of replication/ad-
aptations of PACT have been published where
patients were randomized either to PACT or
the existing best standard practice. One such
study occurred in Kent County, MI and is
known as the “Harbinger” program.18 Patients
who would otherwise have been hospitalized
were randomly assigned either to the Har-
binger (PACT) program or to the existing treat-
ment system. A 30-month followup revealed
marked reductions in total number of patient
hospital beds-days for patients in the PACT
group. While there were no differences be-
tween controls and experimentals on symp-
tomatology, there were advantages in psycho-

social adjustment for the experimental
(PACT) group. The Harbinger (PACT) pa-
tients were more apt to be in daily work set-
tings and making money than the controls, and
psychological tests indicated better mental and
social adjustment. At 1 8 months, costs for con-
trols and experimental patients were about the
same, but at 30 months, costs per year were
reported to be significantly lower for the Har-
binger (PACT) patients.17’ 18

Hoult and colleagues in Sydney, Australia
evaluated a PACT team’s effectiveness as an
alternative to traditional inpatient care and
community aftercare. Results at the end of one
year revealed that fewer of the PACT patients
had been hospitalized or rehospitalized and
that PACT patients had spent markedly fewer
average days in the hospital than controls (a
mean of 8.4 versus 53.5 days).17’ 19’ 20 The
PACT program was considered to be signifi-
cantly more satisfactory and helpful by pa-
tients and by their relatives, and cost less than
the standard care and aftercare.17’ 21

COMMENT

The modern treatment of individuals with
severe psychiatric disorders such as schizo-
phrenia should include both an understanding
of each patient’s pharmacokinetic and dose-
response profile for each effective medication,
and a thorough investigation of the patient’s
impairment including assessments of premor-
bid and current assets and deficits, a delinea-
tion of potential stressors leading to relapse,
and effective mechanisms of social, occupa-
tional, and residential support. Interventions
must address specific impairments in func-
tioning and provide structured training to en-
hance the ability to cope effectively and
maximize compliance with prescribed medi-
cations.

Further, when a schizophrenic patient is left
alone they are likely to become socially iso-
lated. As such, their social role functioning
worsens. Helping the disabled, physically or
mentally, to engage in productive and mean-
ingful activity while treating them with respect
as individuals, enhances and improves their
ability to function.

Determinants of the course of a chronic
mental illness such as schizophrenia include
symptom severity, response to medications.

512

The Journal of the South Carolina Medical Association

SCHIZOPHRENIA

and the level of functional disability. The
course is further determined by the response of
our health care system in providing effective
treatments and rehabilitation. Our usual of-
fice-based systems of care which depend on
compliance with treatments are inappropriate,
ineffective, and inefficient for the schizo-
phrenic individual whose cognitive deficits in-
terfere with judgment. Cognitively disabled
individuals should not be expected to be medi-
cation compliant, or to sustain employment
without adequate on-the-job support, or to ne-
gotiate effectively for decent housing.

Treatment systems must be redesigned so
that missing appointments does not result in
poor medication compliance or worse, the
“closing” of an active file, meaning that no
further action is taken to engage the patient in
treatment. Valid and reliable guidelines have
been established for effective approaches to the
treatment of schizophrenia, including both the
use of medications and a protocol which out-
lines basic parameters for effective interac-
tions with patients and their relatives and
friends. A system of care must also be imple-
mented which assures compliance with medi-
cations and monitors daily activity. For indi-
viduals with schizophrenia, the healthcare
team must advocate for the patient in all as-
pects of life.

The above principles of rehabilitation are
critical to the care of individuals with schizo-
phrenia in Programs for Assertive Community7
Treatment (PACT). This innovative treatment
approach is now available to the chronically
mentally ill in our state. The South Carolina
Department of Mental Health has chosen this
sendee delivery model as part of their commu-
nity services. Given the research findings
herein reviewed, we can anticipate that these
programs will achieve the following goals: (1)
to retain patients in treatment and minimize
psychiatric hospitalization; (2) to develop op-
portunities for meaningful activities and paid
employment; (3) to provide social support and
a social network; and (4) to procure living
arrangements that are comfortable and well
maintained. This is the most optimistic, re-
search-based outcome ever offered to South
Carolinians with chronic mental illnesses.
These full-time, full-service teams are interna-
tionally recognized as “state of the art” ap-

proaches to severe and chronic mental dis-
orders. South Carolina is thus a leader with
regards to utilization of advancements in car-
ing for a previously neglected and often dis-
criminated-against group of patients. □

REFERENCES

1. Andreasen NC. Olsen S: Negative v positive schizo-
phrenia. Arch Gen Psychiatry 39:789-794. 1982.

2. Talbott JA: The chronic mentally ill: what do we now
know, and why aren’t we implementing what we
know? The Chronic Mental Patient II. ed by W. Walter
Menninger and Gerald Hannah. APPI. 1987.

3. Hogarty GE: Depot neuroleptics: the relevance of psy-
chosocial factors — a United States perspective. J Clin
Psychiatry 45 [5. Sec. 2]:36-42, 1984.

4. Torrev EF: Surviving Schizophrenia. Harper and Row,
New York. 1983.

5. Hogarty GE. Anderson CM: Medication, family, psy-
choeducation. and social skills training: first year re-
lapse results of a controlled study. Psychophar-
macology Bulletin 22:860-862, 1986.

6. Stevens JR: Neuropathology of schizophrenia. Ar-
chives of General Psychiatry 39:1 131-1 139, 1982.

7. Reveley MA: CT scans in schizophrenia. British Jour-
nal of Psychiatry 146:367-371, 1985.

8. Andreasen N. et al: Structural abnormalities in the
frontal system in schizophrenia: a MRI study. Archives
of General Psychiatry 46:136-144, 1986.

9. Weinberger DR: Implications of normal brain devel-
opment for the pathogenesis of schizophrenia. .4r-
chives of General Psychiatry ■ 44:660-669, 1987.

10. Liberman PR (ed): Psychiatric Rehabilitation of
Chronic Mental Patients. American Psychiatric Press.
Inc., 1988.

1 1 . Torrev EF: Continuous treatment teams in the care of
the chronic mentallv ill. Hospital and Community
Psychiatry 37:1243-1247, 1986.

12. Stein LI. Test MA: .Alternatives to mental health hos-
pital treatment, I. Conceptual model, treatment pro-
gram. and clinical evaluation. Archives of General
Psychiatry 37:392-397, 1980.

13. Knoedler W (Director. Program for Assertive Com-
munity Treatment. Madison. Wisconsin): Personal
Communication.

14. WTeisbrod BA, Test MA. Stein LI: .Alternative to men-
tal hospital treatment: III. Economic benefit-cost anal-
ysis. Archives of General Psychiatry, 37:400-405. 1980.

15. Test MA. Stein LI: Alternative to mental hospital
treatment: III. Social cost. Archives of General Psvchia-
try 37:1243-1247, 1986.

16. Test MA. Knoedler WH. Allness DJ: The long-term
treatment of young schizophrenics in a community
support program, in LI Stein. MA Test (eds): The
Training in Community Living Model: A Decade of
Experience. New Directions for Mental Health Ser-
vices, No. 26, San Francisco. Jossey Bass, 17-27, 1985.

17. Test MA: The training in community living model:
delivery treatment and rehabilitation sendees through
a continuous treatment team, in RP Liberman (ed.):
Rehabilitation of the Seriously Mentally III. New York.
Plenum (in press).

18. Mulder R: Final evaluation of the Harbinger program
as a demonstration project. Unpublished manuscript.
August 1982.

November 1989

513

19. Hoult J: Community care of the acutely mentally ill.
British Journal of Psychiatry 149:137-144, 1986.

20. Hoult J, Reynolds J: Psychiatric Hospital versus Com-
munity Treatment. Department of Health N.S.W.,
State Health Publication No (HSR) 83-046 Sidney,
Australia, 1983.

2 1 . Reynolds I, Hoult JE: The relatives of the mentally ill:
A comparative trial of community-oriented and hos-
pital-oriented psychiatric care. Journal of Nervous and
Mental Disease, 172:480-489, 1984.

This space contributed
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514

The Journal of the South Carolina Medical Association

NEWSLETTER

MEDICARE UPDATE

Physician Reimbursement Reduced Effective October 17. 1989

Effective October 17, Medicare payments to physicians were
reduced by 2.092 percent as a result of the Graham-Rudman-
Hollings provisions of the budget reconciliation bill.

Oxygen Certification Forms

Physicians are reminded that they must complete Oxygen
Certification Forms (HCFA 484) ; do not allow the supplier to
complete this form. The Office of the Inspector General plans to
monitor this service carefully.

ICD-9-CM Changes

Certain changes in ICD-9-CM codes were effective October 1, 1989.
These changes were provided to you in a September Medicare
Advisory by Blue Cross and Blue Shield of SC.

MEDICAID UPDATE

EPSDT Program

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Program provides comprehensive and preventive health services to
Medicaid eligible children from birth to age 21 through periodic
medical screenings.

Physicians participating in the program must be licensed and/or
certified by the appropriate standard setting agency to provide
services covered by SC Medicaid. Physicians should contact The
Computer Company at 1-787-4961 for Medicaid enrollment. Upon
notification of Medicaid enrollment, the physician should contact
the Division of Preventive Care at 1-253-6121 for EPSDT
enrollment.

A screening will be reimbursed at $45.00 for the first five
screenings up to age one. All subsequent screenings up to age 21
will be reimbursed at $38.00. This fee is all inclusive,
although screening services vary according to age and periodicity
schedule.

Obstetric and Gynecology Reimbursement Rates Increased

As a reminder, effective July 1, 1989, the following rates
applied for the procedures listed:

Code

Description

Rate

59410

Vaginal Delivery

$700.00

59500

C-Section

$800.00

59520

Antepartum

$ 20.00

59530

Post Partum

$ 20.00

58600

Tubal Ligation

$442.00

58605

Tubal Ligation - Post Partum

$387.00

58611

Tubal Ligation - C-Section

$221.00

PRO UPDATE

CMR Conference Calls Available for Physicians

Carolina Medical Review (CMR) wishes to remind physicians that
they are entitled to a telephone conference with a PRO physician
or non-physician representative, as appropriate, concerning a
case. However, the physician must request a conference call in
the written response to the initial inquiry. The purpose of the
conference is to allow additional or clarifying information to be
provided in the case file, which will then be reviewed for a
final decision.

Please make note of the following:

1. No decision will be rendered in the telephone conference.

2. Telephone conferences are only allowed after initial
inquiries from CMR ("20 or 30 day" letters) , not for
reconsiderations after adverse decisions.

3. Requests must be in writing.

In most cases, the information provided by the physician in the
written response to the initial inquiry is enough to approve the
case, without the need of a telephone call. However, if an
adverse determination results and a telephone call has not yet
taken place, then physicians are urged to contact the CMR Medical
Advisor.

AIDS UPDATE

HIV/AIDS Resources and Information Network Guide Available

A statewide HIV/AIDS resources and information network guide
entitled "Sharing" has been published by the HIV/AIDS Division
of the Bureau of Preventive Health Services, SC DHEC. "Sharing"
was developed to provide health care professionals with a single
compilation of resources to assist their AIDS and HIV patients in
obtaining needed services. It includes information on education
and prevention services available in SC, such as physicians
treating HIV/AIDS patients, mental health centers, testing and
counseling, legal agencies and spiritual support. Services are
listed by county for easy usage.

Copies are available at no charge by contacting the Editor,
Patrick Barresi, MPH, HIV/AIDS Division, SC DHEC, 2600 Bull
Street, Columbia, SC 29201, 737-4110.

FREE VACCINES FOR INDIGENT PATIENTS

Physicians who agree to immunize indigent and EPSDT patients at
no charge for the vaccine are eligible to receive free vaccines
from DHEC. No free vaccines can be provided without a "Letter of
Application" on file with DHEC*s Division of Immunization and
Prevention. This letter sets forth the following additional
conditions to which the physician must agree:

1. Immunize patients at no charge or for a reasonable
administrative fee of no more than $3.00.

2. Assume responsibility for informing each patient on benefits
vs. risks of immunization and use "Important Information
Statements" furnished by DHEC in clinic type settings where
individualized medical judgments are not made.

3 . Maintain and submit a quarterly vaccine report to the
Division of Immunization and Prevention by the 5th day of
each quarter. This report consists of the number of doses of
vaccines administered to indigent patients by age and vaccine
type. This allows DHEC to be reimbursed for the vaccine.

4. Maintain and submit a quarterly vaccine report to HHSFC .

This report consists of the number of doses of vaccine
administered to EPSDT patients by age and vaccine type. The
report should also contain any other identifying information
required by HHSFC.

Physicians must use their own criteria for determining indigence.
The current vaccine program is subject to availability of funds
and vaccine, and the degree of cooperation by private physicians
with regard to the necessary requirements.

To obtain a "Letter of Application" or for additional
information, contact the Division of Immunization and Prevention
in Columbia at 737-4160.

HEALTH CARE QUALITY ASSURANCE ACT OF 1986

Physicians should take note that the Health Care Quality
Assurance Act of 1986 (42 U.S.C. 11112 et . sea. ) became
applicable in South Carolina on October 14.

While the regulations and computer data base for the reporting
process will not be on line until early 1990, physicians,
especially those serving on hospital medical staffs, should note
that the due process requirements for professional peer review
proceedings are applicable immediately, from October 14 on.

Questions about the Act should be directed to Steve Williams at
the SCMA .

PHYSICIAN BILLING UNDER CROSS -COVERAGE ARRANGEMENTS

In last month’s newsletter, it was reported that physicians in
another state encountered problems with their Medicaid agency
when they billed for their patients although another physician
had covered for them. A clarification was provided by Blue Cross
and Blue Shield of SC with regard to Medicare. The following
statement has since been issued by HHSFC with regard to Medicaid:

"A physician can bill for those services rendered by another
physician as long as (1) the covering physician is not seeing
these patients as a routine part of his/her practice; (2) the
primary physician understands that he/she is responsible for
services rendered by the covering physician that are billed by
him/her to Medicaid; and (3) both physicians do not bill for
services rendered."

NOMINATIONS BEING ACCEPTED FOR MATERNAL AND CHILD HEALTH AWARDS

The Bureau of . Maternal and Child Health, DHEC, in cooperation
with HHSFC and the Governor’s office, wishes to recognize and
commend individual physicians who have made outstanding
contributions in expanding Medicaid and improving access to
health care for mothers and children. Awards will be made at the
Annual Maternal and Child Health Awards Ceremony on December 13,
1989. Nominations should be received by November 24, 1989. For
a nomination form, contact Christine Mayers or Joanne Fraser in
Columbia at 737-4190.

HOTLINE PHONE NUMBERS: PRENATAL PATIENTS

If your prenatal patients are having trouble obtaining Medicaid
or other social services, you or your patients can call the
Pregnancy Hotline number at 1-800-868-0404 (or in Columbia, 737-
3998) to obtain assistance.

HURRICANE DAMAGE LOAN FUND ESTABLISHED

The Board of Trustees of the SCMA has established a $500,000
Hurricane Damage Loan Fund to aid members in maintaining their
practice. The AMA has committed an additional $500,000 for loans
to member physicians in SC. Loans of up to $10,000 per eligible
member or a maximum of $25,000 for groups of three or more
members, will be made available for repairing or replacing
damaged equipment and supplies, for making necessary repairs to,
or relocation of, professional offices and for maintaining cash
flow to meet necessary expenses.

Applications must be submitted between now and January 31, 1990.
To obtain a loan application, call or write Mr. Wayne Cox at the
SCMA Headquarters.

SPECIAL ELECTION RESULTS

The South Carolina Political Action Committee (SOCPAC) supported
successful candidates Marion "Son” Kinon (D) for House District
#55 and Holly Cork (R) for House District #123. From Dillon,
Kinon is a former Circuit Judge and former Representative (1957-
1960, 1978-1979) . He filled the seat vacated by James Lockemy
who became Circuit Judge. Cork, from Hilton Head, formerly
worked with Congressman Arthur Ravenel. She filled the seat
previously held by her late father, Bill Cork.

SOCPAC also supported Leone Castles (R) from Columbia, who lost a
close race to Jim Harrison (R) for House District #76 in a
primary run-off election. Harrison faces Democrat Lyles Glenn in
the November General Election. Castles is the wife of C. Guy
Castles, Jr., MD.

AMA VIEWED AS LEGISLATIVELY EFFECTIVE

In the view of senior congressional staff members, the American
Medical Association is one of the fiv6 national organizations
most effective in achieving its legislative goals. That
assessment came from a survey conducted last spring by two
opinion-gathering research firms. The firms, which periodically
conduct the survey, hold open-ended, confidential interviews with
top staff from about one-fourth of all Senate and House offices.

GRANTS - IN- AI D FROM AMERICAN HEART ASSOCIATION. SC AFFILIATE

Applications for Grants-in-Aid are now available from the
American Heart Association, SC Affiliate, with a deadline of
December 4, 1989 for submission to the Association's Research
Committee. General requirements are that applicants must have
advanced degrees and contemplate significant basic or
cardiovascular research in a non-profit institution with adequate
facilities for their work. Awards are activated beginning July
1, 1990. Further information and application forms may be
obtained from the AHA, SC Affiliate, PO Box 6604, Columbia, SC
29260.

This research program is separate from that of the American Heart
Association, National Center, which also makes research awards to
scientists in SC. Deadlines are June 1, 1990 for Fellowships and
July 1, 1990 for Grants-in-Aid. Those interested in inquiring
about the national program may write the Director of Research,
American Heart Association, 7320 Greenville Ave., Dallas, TX
75231.

AMA WORKSHOP ON HIV COUNSELING

The AMA and the Florida Academy of Family Physicians are
cosponsoring a workshop on HIV blood test counseling on Saturday,
December 2, at the Marriott Orlando World Center in Orlando. The
purpose of the workshop is to provide physicians with sound

guidance on how to incorporate effective pre- and post-test HIV
counseling in their patient care. Physicians will be informed
what works and doesn't work in HIV counseling.

Although not every physician will treat AIDS patients, nearly all
will come into contact with patients who are, or may become, HIV
positive. Since the incidence of HIV disease is continuing to
increase, there is a corresponding need for early identification
and HIV testing.

Workshop participants can obtain seven hours of Category I CME
credit toward' s AMA's Physician Recognition Award.

For additional information, call AMA's Division of Health Science
at 312-645-5563. To make room reservations at the Marriott
Orlando World Center, call 407-239-4200 and identify yourself as
being a workshop participant.

1989 SCMA MEMBERSHIP YEAR

Two county medical societies, Bamberg and Hampton, ended the 1989
SCMA membership year with 100 percent participation. Chester
followed closely behind with 95 percent. Spartanburg County

Medical Society, with a total membership of 336, had 262 members
in the SCMA, or 78 percent. Final totals for 1989 indicated
2,904 active members, 109 new members, 288 honorary and disabled
members, 162 residents and 319 students.

CAPSULES

Thomas C. Rowland, Jr., MD, SCMA immediate past president, was
elected Chairman of the Council of the Southern Medical

Association at its 83rd Annual Scientific Assembly in Washington,
DC.

The Georgetown County Medical Society has initiated a nursing
scholarship to be awarded annually to a member of the nursing
profession at Georgetown Memorial Hospital who might desire to
further his or her education in nursing.

The SC Society of Internal Medicine was awarded ASIM's Component
Society Membership Improvement Award at ASIM's Annual Meeting in
October in Washington, DC, for outstanding improvements in

membership growth during the 1989 dues year. ASIM recognized

SCSIM for extensive personal recruitment and retention
activities, which culminated in a 20 percent increase in
membership this year.

SCMA NEWSLETTER
is a publication of the
South Carolina Medical Association
Contributions welcomed.

Melanie Kohn, Editor
Joy Drennen, Assistant Editor

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Hydrochloride.

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its
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system effect is to increase parasympathetic (cholinergic) and decrease
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performance, erection is linked to cholinergic activity and to alpha-2 ad-
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decreased penile outflow or both.

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anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug. Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone.

Reportedly. Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it; however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.

Indications: Yocon1 is indicated as a sympathicoiytic and mydriatric. it may
have activity as an aphrodisiac.

Contraindications: Renal diseases, and patient’s sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.1-2 Also dizziness,
headache, skin flushing reported when used orally.1-3
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence. 1 -3-4 1 tablet (5.4 mg) 3 times a day. to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to Vi tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of Yocon« 1/12 gr. 5.4 mg in

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References:

1. A. Morales et al. , New England Journal of Medi-
cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed..p. 176-188.

McMillan December Rev. 1/85.

3. Weekly Urological Clinical letter, 27:2, July 4,

1983.

4. A. Morales et al. , The Journal of Urology 128:

45-47, 1982.

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November 1989

521

DYNAMIC AUSCULTATION*

RICHARD S. POLLITZER, M.D.**
STEPHEN L. WATKINS, M.D.
TIMOTHY S. LLEWELYN, M.D.

Cardiac murmurs, gallops, opening snaps,
and other tones have acquired new signifi-
cance in the last few months because of balloon
angioplasty for stenoses of the aortic and
mitral valves.1' 2

Every physician learned in medical school
that these cardiac noises can often be evaluated
at the bedside by simple maneuvers such as
straining, handgrip, squatting, etc. These tech-
niques, known as dynamic auscultation, have
been made more precise, because of recent
research, as described in detail by the authors
of several excellent textbooks3'6 and articles.7

In lecturing to our House Staff and to prac-
ticing physicians, however, we found that they
had difficulty in remembering the effects of
several different maneuvers on a number of
different events in the cardiac cycle.

Accordingly, we constructed a tabular chart,
which is shown in the accompanying figure.
The top line of the chart lists various heart
sounds, in the sequence in which they or-
dinarily occur. At the left of the chart, listed
vertically, are some of the maneuvers, starting
with those which are simple and entirely safe;
at the lower portion of the chart are described
those maneuvers which are marked “avoid if
danger of ischemia or arrhythmia.”

In the chart, an upward pointing arrow indi-
cates that a given heart sound is increased by a
certain maneuver. For example, the murmur
of aortic stenosis is louder about five seconds
after the patient does a Valsalva strain. The
murmur of mitral stenosis is increased by iso-
metric handgrip.

By combining several maneuvers, the physi-
cian can greatly increase the intensity of many
heart sounds, thus providing more informa-
tion about cardiac diagnosis.

We have found it helpful to make copies of
this chart and keep them in our examining
rooms. □

REFERENCES

1. McKay RG, et. al: Percutaneous Mitral Valvuloplasty
in an Adult Patient With Calcific Rheumatic Mitral
Stenosis. J AC Cardiology 6:1410-5, 1986.

2. Safian RD, et. al: Postmortem and Intraoperative Bal-
loon Valvuloplasty of Calcific Aortic Stenosis in Elderly
Patients: Mechanisms of Successful Dilation. J AC
Cardiology 9:655-60, 1987.

3. Gazes PC: Clinical Cardiology, Chicago, Yearbook
Publishers, 1987.

4. Hurst JW: The Heart, New York, McGraw-Hill, 1986.

5. Braunwald E: Heart Disease, Philadelphia, W. B. Saun-
ders Co., 1984.

6. Criscitiello MG: Physiologic and Pharmacologic Aides
to Auscultation, in Fowler, Noble O (Ed), Cardiac Diag-
nosis and Therapy, Hagerstown, Harper and Row,
1980.

7. Crawford MH and O’Rourke RA: A Systematic Ap-
proach to the Bedside Differentiation of Cardiac Mur-
murs and Abnormal Sounds, in Harvey, W. Proctor,
(Ed), Current Problems in Cardiology, Chicago, Year-
book Medical Publishers, 1977.

* From the Doctor’s Medical Center, Spartanburg, S. C.

** Address correspondence to Dr. Pollitzer at the Doctor’s
Medical Center, 391 Serpentine Drive, Suite 550, Spar-
tanburg, S. C. 29303.

522

The Journal of the South Carolina Medical Association

DYNAMIC AUSCULTATION

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Route 16...

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ACCESS TO ONLINE INFORMATION:
THE HARDWARE CONNECTION

NANCY SMITH, M.L.S.*

Access to medical information has changed
dramatically in the last five years. Information
which was once only available by subscribing
to journals, purchasing medical texts and di-
rectories, or visiting the hospital or medical
school library is now packaged for delivery to
your home or office desktop through a tele-
phone line. The major database vendors have
customized their systems to provide ease-of-
use by busy health care professionals. 1 A profu-
sion of medical information is readily avail-
able in a “user-friendly” format, but how do
you get to it? How do you go from desktop to
database? What equipment is required?

A microcomputer, a modem, a telephone
line, and a printer are the four basic “hard-
ware” components needed for “online” access
to medical information.

While a low-cost ($400-$600) terminal could
be used instead of the microcomputer ($800-
$3000), the flexibility and data storage ca-
pability of the micro would be lost. Assuming,
then, that a microcomputer is used, which one
is best? It doesn’t matter. Apples, IBM-XTs,
-ATs, PS/2s, IBM-clones of all descriptions,
COMPAQs, Macintoshes, laptops and porta-
bles all serve equally well as online search
machines. The “ideal” microcomputer would
have at least 640K of random access memory
(RAM), one floppy diskette drive, one hard
disk drive with at least 20 megabytes of storage,
one parallel port, one serial port, and a color
monitor. The suggested capabilities are not re-
quirements; online searching can be conducted
by a machine with no memory, no storage
capability, and no color. This “ideal” is pre-
sented as a workstation that would provide
ease of use in online searching, ports for attach-
ing a printer and a modem, and flexibility for
other microcomputer applications such as
word processing, small office management,

* Library, Medical University of South Carolina, 171 Ash-
ley Avenue, Charleston, S. C. 29425-3001.

and continuing medical education.

An issue of greater concern is which modem
is best? The modem translates, or modulates,
digital signals sent by the microcomputer into
analog signals that can be carried by telephone
lines. When incoming telephone/analog sig-
nals are received by the modem, they are trans-
lated, or demodulated, back into digital signals
that can be accepted by the microcomputer.
Because of close association with the tele-
communications industry, modems are the
most standardized component of the online
searcher’s workstation. While the brand name
is not important, a modem’s ability to support
several telecommunication standards is essen-
tial. It should support the “Hayes” or “AT”
command set and certain Bell standards (212A
for 1200 bits-per-second transmission; CCITV
V.22bis for 2400 bits-per-second transmis-
sion). While extremely fast data transfer speeds
of 9600 baud and higher are currently the rage
in micro-telecommunications circles, a mo-
dem that can transmit and receive at 300, 1 200,
and 2400 baud is best for online searching.
This variety of speeds will provide com-
patibility with a wide range of services, from
low-speed bulletin boards and conferencing
centers to the popular commercial database
services such as MEDLARS, BRS, DIALOG,
COMPUSERVE, etc.

Most modems are “direct-connect.” That is,
they come with a telephone line that plugs
directly into a standard wall jack (known as an
RJ-11C). Modems can be internal (contained
on a circuit board that is inserted into a slot
inside your microcomputer) or external (a sep-
arate “box” that is cabled to the microcom-
puter’s serial port). An internal modem,
usually less expensive than an external
modem, does not use additional desk space
and provides its own serial interface to the
microcomputer, but does occupy valuable
space inside the micro and can be difficult to

November 1989

527

INFORMATION MANAGEMENT

troubleshoot. Internal modems range in price
from $100-$300; external modems from
$150-$450.

The telephone line, an essential ingredient in
“online” searching, is often the most vexatious
component of the workstation. “Line noise” or
random electronic impulses can interrupt the
data exchange between your microcomputer
and the remote computer. Although it is diffi-
cult to eliminate completely, line noise can be
quieted by using a single rather than a multi-
user phone line, disabling “call waiting,” and
installing a line filter device.

The standards that apply to printer selection
are your personal standards for quality, speed,
quietness, and versatility. An inexpensive
($300-$400) dot matrix printer will perform
well as an online workstation printer, but its
quality may not be acceptable for business cor-
respondence or publication proofs. A mid-
range ($400-$700) inkjet printer is very quiet
but usually requires special, more expensive,
paper, and still may not provide correspon-
dence quality print. The very expensive
($1000-$3000) laser printer produces the high-
est quality print, but is an extravagance for a
printer dedicated to online searching. How
much you wish to spend and how many differ-
ent applications the printer will be used for are
generally the determining factors in printer
selection.

In addition to the four basic hardware com-
ponents, an online microcomputer work-
station must have communications software.
Communications software is the set of in-
structions that enables all of the hardware to
work together productively. Good commu-
nications software supports a wide variety of
terminal emulation types (e.g., TTY, VT100,
IBM3101) enabling the microcomputer to
“talk with” a multitude of large computers.
Most communications software provides a
“dialing directory” or “phonebook” where
phone numbers and line settings (i.e., baud
rate, parity, data word length, stop bits, etc.)
used to access each remote system can be
stored for reuse. At the time of a call, one or two
keys are pressed and the software does the rest.

Some communications software programs
provide a “scripting” or programming feature
that allows customization for automatic online

sessions. In some packages, this capability is
limited to an automatic log-on which transmits
a username and password to each system. In
other, more sophisticated packages, the script-
ing capability allows all search terms to be
entered prior to placing the phone call to the
remote computer; the entire search session,
including the “downloading” of retrieved ref-
erences, is conducted automatically.

Downloading is the process of receiving data
from the remote computer to a disk file on your
microcomputer. Downloading generally saves
online time; the computer can write to a file
faster than a printer can print. It also saves a
copy of the data that can be manipulated “off-
line” using other software such as word pro-
cessing, spreadsheet, or database management
programs. There is, however, one major caveat
to downloading: it may be a violation of
copyright law. Vendor subscription agree-
ments will state the downloading policy.

Good communications software can cost
from $50-$ 300. The package’s expense does
not necessarily correlate with its quality or
“useability.” There are “shareware” programs
available at no or low initial cost through local
personal computer user groups and electronic
bulletin boards. Shareware provides a “try-
before-you-buy” option. If the package is
found to be useful, remittance of a modest fee
to the software developer is in order. Commu-
nications software can also be obtained com-
mercially through computer stores or mail
order. Some modem manufacturers include
“free” communications software with the pur-
chase of their modem. As with most of the
components of the online searcher’s work-
station, once fundamental features are sup-
ported, the selection of communications
software is mostly dependent upon personal
choice.

These, then, are the necessary tools: a micro-
computer, a modem, a telephone line, a
printer, and communications software. Now
all that’s needed is a little time to acquaint
yourself with the convenience and power of
accessing medical information online. □

REFERENCE

1. Towell, FJ: The Physicians’ friend: user-friendly bibli-
ographic and informational databases. JSC Med Assoc

84:307-8, 1988.

528

The Journal of the South Carolina Medical Association

ONLINE INFORMATION MANAGEMENT:
WHO NEEDS IT?

NANCY C. McKEEHAN, M.S.L.S.*

“Science is a sort of conspiracy that
makes knowledge run faster than
people ”

— Derek de Solla Price1

How often, in the course of your office day
do medical questions go unanswered? How
often do you feel the need to consult the liter-
ature for advice on diagnosis or a course of
treatment? How satisfied are you with your
ability to stay abreast of and assimilate the
latest developments in your specialty? Dr.
Octo Barnett, of Harvard Medical School, cal-
culates that “if you read two articles a night, at
the end of one year you’d be 355 years
behind.”2

Studies have shown that physicians have a
real need for better access to information in
their daily practice. Covell found that “an-
swers to questions raised at the time of the
patient visit were found only 30% of the time;
in a typical half day of office practice, four
management decisions might have been al-
tered if needed information had been available
at the time of the patient visit.”3 In a study by
Dabanovic, 20% of the doctors interviewed
said that the information supplied to them
“directly influenced their treatment of patients
and altered their methods” of patient care.4
Strasser documents that rural physicians both
feel the greatest need and have the most diffi-
culty in obtaining information.5 In a recent
editorial, Stead acknowledges a similar con-
cern felt by outlying physicians and admin-
istrators in small hospitals: that patients will
“drive right by them” to seek medical care in
the larger cities. Offering a solution, Stead dis-
cusses the accessibility of the National Library
of Medicine’s (NLM) MEDLINE database as
“the great equalizer.”6
Davies discusses access to online informa-

* Library, Medical University of South Carolina, 171 Ash-

ley Avenue, Charleston, S. C. 29425-3001.

tion as both a time-saving and cost-saving
measure for the physician. He points out the
inefficiencies of the traditional “garbage can
method” of problem-solving, whereby physi-
cians sift through thousands of disconnected
threads of factual information to reach a deci-
sion and contrasts the ease and speed of con-
ducting an online literature search.7 During a
search, significant terms are entered into a
computer, which then does the work of com-
bining them and logically applies them to the
database. The results are limited to meaningful
possibilities which may point the way to ap-
propriate testing or treatment. The cost for
such a search may be less than $10.00 and the
savings in time, and possibly wasted effort, will
be significant.

Medicine is an information-intensive pro-
fession. The well-known “literature explo-
sion” has become a time-worn cliche. Yet it is
nonetheless real, and complicates the physi-
cian’s need for current, readily accessible infor-
mation. Fortunately, there is a solution which
is both economical and practical: the use of
microcomputers to access online information
services designed for use by clinicians. But how
do you begin and what will it cost to get started
with online searching?

Online access to current medical informa-
tion is available to all South Carolina physi-
cians through SCHIN, the South Carolina
Health Information Network.** With a micro-
computer or video display terminal and a
modem, physicians can access the major medi-
cal library collections in the state. Over
268,000 books, journals and audiovisuals con-
tained in 31 libraries, including the Medical
University of South Carolina and the Univer-
sity of South Carolina School of Medicine
comprise the catalog databases of SCHIN. In
addition to the online catalogs, SCHIN offers

** This program was initially supported by NIH Grant No.

5 G08 LM 04271 from the National Library of

Medicine.

November 1989

529

ONLINE INFORMATION

miniMEDLINE,™* a journal citation data-
base representing over 350,000 articles pub-
lished in the past three years in 350 of the most
significant and widely read medical journals.

The SCHIN databases are easy to search, yet
offer the sophisticated capabilities inherent in
online database searching. Terms can be com-
bined in a keyword search to refine retrieval in
the catalogs to very specific subject areas or
time periods. Conversely, if all available liter-
ature on a disease is needed, the system quickly
gathers and displays the titles of books, audio-
visual programs, or journals, from which the
most appropriate may be selected for use. A
major advantage of the online catalog is the
presence of both location and status informa-
tion. When a title is searched, it is readily
apparent which libraries hold it and whether
the volume is available for use.

SCHIN’s miniMEDLINE™ system is a
carefully profiled subset of the MEDLINE
database. Monthly updates keep the database
current, offering online access to the latest
journal literature. The availability of abstracts
for over 60% of the citations in miniMED-
LINE™ enhances its usefulness and often pre-
cludes the need to consult the full article.
Should a search of the miniMEDLINE™
database indicate the need for a broader liter-
ature search, the full MEDLINE system is ac-
cessible to SCHIN members using a software
package called Grateful Med.

Grateful Med is supplied as part of SCHIN
membership. Developed at the National Li-
brary of Medicine (NLM), it offers user-
friendly access to MEDLINE and other data-
bases at NLM. The program assists the user in
each step of the search and does not require use
of the special command language used by
highly-trained librarian searchers. In contrast
to miniMEDLINE,™ a search on MEDLINE
covers almost six million citations in over

* miniMEDLINE is a registered trademark of the
Dahlgren Memorial Library, Georgetown University
Medical Center.

3000 medical journals published worldwide
since 1966.

Membership in SCHIN is open to all health
professionals in the state and costs $ 100.00 per
year. In addition to the databases described,
SCHIN offers members reduced fees for infor-
mation services such as literature searches and
document delivery from SCHIN member li-
braries in the state. This includes libraries at
both the Medical University of South Carolina
and the USC School of Medicine; state agen-
cies such as DHEC, the Department of Mental
Health, and the Commission on Alcohol and
Drug Abuse; and over 20 state, federal, and
private hospitals across South Carolina.

The accessibility of SCHIN and other online
information services relieves the practitioner
of the burden of collecting, organizing, and
retrieving the knowledge contained in the jour-
nals and books which may be at hand, but
remain unread and unassimilated. In South
Carolina, SCHIN is addressing online infor-
mation management by providing access to
current medical information to any practi-
tioner with a microcomputer and a telephone
line.** □

REFERENCES

1. Price D: The Development and structure of the bio-
medical literature. In: Warren KS, ed. Coping with the
biomedical literature. New York: Praeger. 1981:3-16.

2. Goldman B: Computers in health care: we’re entering a
new phase. Can Med Assoc J 136:1201-6, 1987.

3. Coveil DG, Uman GC, Manning PR: Information
needs in office practice: are they being met? Ann Intern
Med 103:596-9, 1985.

4. Dabanovic R: How the literature can help in medical
treatment. Int J Clin Pharm Res 5:1-7, 1985.

5. Strasser TC: The Information needs of practicing physi-
cians in northeastern New York state. Bull Med Libr
Assoc 66:200-9, 1978.

6. Stead EA: The National Library of Medicine: the great
equalizer between small hospitals and major medical
centers. NC Med J 49:360, 1988.

7. Davies NE: The National Library of Medicine, comput-
ers, and the garbage can method of problem solving. J
Med Assoc Ga 77:638-42, 1988.

** For information about SCHIN membership, call the
Library Systems Office at the Medical University of
South Carolina (792-7672) or write the author.

530

The Journal of the South Carolina Medical Association

Editorials

INTO THE FRAY: THE COMMUNITY HOSPITAL TREATMENT
OF ACUTE MYOCARDIAL INFARCTION

The article by Trask, et al in this issue of The
Journal reports the data on the efficacy of
thrombolytic therapy for acute myocardial in-
farction in community hospitals. This
therapeutic approach not only restores coro-
nary artery patency and reduces mortality but
lessens morbidity by improving left ven-
tricular function.

In the TIMI-II-B trial the overall mortality
of patients under age 75 was reduced to a re-
markable five percent in six weeks. The use of
intravenous beta blockers in the early hours of
infarction suggested additional benefits for re-
ducing re-infarction. It was also Teamed that
angioplasty (PTCA) performed in the first or
second day after Tissue Plasminogen Ac-
tivator (TPA) did not decrease mortality or
improve left ventricular function in stable pa-
tients. An unexpected finding was that a signif-
icant number of acute myocardial infarctions
that were stable did not require immediate
catheterization and, if no evidence of ischemia
was present on further follow up on non invas-
ive testing, would not require coronary angiog-
raphy.

The International Study on Infarct Survival
(ISIS-II) suggested that Streptokinase and as-
pirin were equally effective in reducing acute
myocardial infarction mortality and the two
given together were better than either alone.

As one reviews the literature in an attempt to
absorb the rapidly advancing and changing
recommendations of TIMI-I and II, and II-B,
TAMI, ISIS I, II, and III, GISI I and II and
TPAT, one point remains constant that is not
open to debate: the need for early intervention.
The best results are obtained within the first
four to six hours, and particularly under two
hours of the onset of chest pain. These time

intervals are being further investigated in nu-
merous clinical trials to determine the relative
effectiveness of therapy initiated after six
hours. Many other questions remain to be an-
swered concerning intravenous Heparin, the
role of APSAC and the vast cost differential in
TPA and Streptokinase.

But the major problem remains before us in
the fact that medicine has yet to transfer these
advances to enough patients to have a signifi-
cant impact on the health care delivery system.
Several large studies reveal that only 1 2 to 1 7%
of patients with acute myocardial infarction
receive appropriate thrombolytic therapy.

Clearly, a significant number do not meet
current established criteria for thrombolytic
therapy and are excluded. It is likely that
thrombolytic therapy is being under-used in
smaller community hospitals since studies
have shown that enthusiasm for this treatment
modality is less in these institutions. Emer-
gency room physicians, family practitioners,
and general internists were considerably less
likely to administer thrombolytic therapy than
cardiologists in heart centers.

It is important, however, that this not be
misinterpreted as promoting widespread use of
thrombolytic therapy simply based on the
premise that we are not treating enough pa-
tients. There can be no substitute for critical
patient selection in keen clinical judgement.

The formation of heart networks has ad-
dressed this problem by continuing education
to professional staffs, Fax equipment for EKG
consultation and 24-hour availability of skilled
professionals. Backup is also furnished for un-
stable patients that would require transfer to
centers for further treatment and invasive pro-
cedures. It is encouraging in our state to see the

November 1989

533

early fruits of this endeavor, but efforts need to
be continually expanded to reach a larger
number of patients. Primary education thrust
should emphasize the need for patients to im-
mediately report to their neighborhood com-
munity hospitals with the onset of chest pain
and not attempt to reach a distant regional
center, and thus avoid a critical delay in treat-
ment initiation. The need and safety of throm-
bolytic therapy in small rural hospitals has

been well established and it is there and not in
tertiary regional centers that most major bat-
tles will be won or lost. The time for commu-
nity hospital treatment of acute myocardial
infarction with thrombolytic therapy is now.

E. Conyers O’Bryan, Jr., M.D.

Director, McLeod Heart Institute

Florence, South Carolina 29501

OF SCHIN AND GRATEFUL MED (OR COMPUTERS
TO THE RESCUE!)

Like it or not, as physicians we are in the
information business. Patients expect the
latest information — and rightly so, for it is
often essential to optimum care. However,
even as entering medical students, we knew
that keeping abreast of an ever-burgeoning lit-
erature would befuddle even the most consci-
entious. We knew that textbooks would never
suffice, but that managing the journal liter-
ature was an almost overwhelming task.

Early in our careers, most of us chose to save
our journals as torn pages in file cabinets or as
bound volumes on bookshelves. That is, we
chose to emulate either Jack the Ripper or
John the Binder. Inexorably, the filing system
became unmanageable or the bookshelves be-
came inadequate. Storing information became
an ever-losing proposition. For years, we heard
the promise that computers would some day
come to our rescue. Promise has now become
reality.

In this issue of The Journal, Nancy C.
McKeehan outlines the basic details of
SCHIN — the South Carolina Health Informa-
tion Network. This program offers not only
online catalogs of medical information but also
miniMEDLINE™, a database of articles pub-
lished over the past three years in 350 or more
of the most widely-read journals. One need not
be a computer wizard, for the program is user-
friendly. Nancy J. Smith, in her companion
article entitled “The Hardware Connection,”
explains how to get started. One might take
Ms. Smith’s article down to the local computer
store for advice about the most cost-effective

computer and modem. Once these have been
purchased and installed, one can access
SCHIN through the library at either of our
state’s medical schools or through the Library
Systems office at the Medical University of
South Carolina (792-7672). I offer but one
warning: it’s addicting.

SCHIN and systems like it — such as the Na-
tional Library of Medicine’s user-friendly
GRATEFUL MED program — reflect the
changing function of medical libraries and
their librarians. As Dr. Warren (Buzz) Sawyer
of MUSC puts it: “We’ve become information
brokers.” Librarians trained to shelve and in-
dex the bound volumes are now expected to
find the most appropriate references and to
furnish the abstracts. Still, the physician-users
must ask the right questions. There is clearly a
need for more physician involvement in the
emerging enterprise of “medical informatics.”1

Dr. Eugene Stead points out that near-in-
stantaneous access to MEDLINE has become
“the great equalizer” between small hospitals
and major medical centers.2 We can ask the
computer to provide us with the best, most
recent articles pertaining to our patient’s prob-
lem. We can seek either review articles or care-
fully cross-referenced articles based on a
combination of concerns. All of us know that
real medical knowledge, the kind that stays
with us, comes from reading prompted by car-
ing for a patient. Computers, then, seem likely
to emerge as the most cost-effective form of
continuing medical education.

Today’s students know that the future be-

534

The Journal of the South Carolina Medical Association

longs not to Jack the Ripper or John the Binder
but rather to the computer whiz. Fortunately,
becoming a computer whiz has become much
easier — for all of us. With little or no fanfare,
the libraries at our state’s medical schools are
cooperating to bring us the best of MEDLINE.
SCHIN seems here to stay. We — and our pa-
tients— should enjoy immense benefits.

— CSB

REFERENCES

1. DeTore AW: Medical informatics: an introduction to
computer technology in medicine. Am J Med 85:
399-403, 1988.

2. Stead EA: The National Library of Medicine: the great
equalizer between small hospitals and major medical
centers. NC Med J 49: 360, 1988.

On tl;e Cover :

ST. LUKE’S CHAPEL AND HURRICANE HUGO

This month’s cover deviates somewhat from
our usual emphasis on medical history to focus
on what will prove to be a major historical
event for the entire state of South Carolina.

On the cover is a photograph of St. Luke’s
Chapel on the campus of the Medical Univer-
sity of South Carolina taken on the balmy day
following the September 21st visitation of
Hurricane Hugo.

St. Luke’s was originally part of the federal
arsenal built between 1825 and 1830. It is
believed to be the first federal property seized
by the South Carolinians following secession.
Because of a kindness shown to a federal officer
during the war, the Reverend Anthony Toomer
Porter was given the arsenal to house the
school he had established for the boys left or-
phaned and destitute by the war. The beautiful
chapel was created in 1883 from a large brick
artillery shed by raising the walls four feet,
adding a gothic roof, closing in the sallyports
and adding stained glass windows. The chancel
window was dedicated to the memory of Dr.
Porter’s son whose death in a yellow fever
epidemic had provided the impetus for the
founding of the school.

When the Medical College acquired the Por-
ter property in 1963, the chapel was rededi-
cated as St. Luke’s in honor of the beloved
physician.

Although it stands in ruins now, there are
plans afoot to restore the chapel to its original
beauty. The remains of the memorial window

have been salvaged and are being kept in the
hope that eventually the window can be
restored.

As the Medical University of South Carolina
has survived fire, earthquake, and civil war
and continued to serve the medical needs of
the people of the state, so it will survive Hugo.

Betty Newsom

The Waring Historical Library

ACKNOWLEDGEMENT
The cover photo is courtesy of Jim Nicholson.

FIGURE 1. St. Luke’s Chapel before Hugo.

November 1989

535

IN MEMORIAM

M. Rodney Culler, M.D., a cardiologist from Orangeburg, died on May 6, 1 989. Dr. Culler was
a graduate of Emory University and the Medical University of South Carolina. He was an
active member of the SCMA.

Alexis B. Calder, M.D., a retired physician from Sumter, died on May 9, 1989. Dr. Calder was
a graduate of Springhill College of Alabama, the College of Charleston and the Medical
University of South Carolina. He was an honorary member of the SCMA.

Joseph H. King, M.D., a general practitioner from Manning, died on May 20, 1989. He was a
graduate of Wofford College and the Medical University of South Carolina. Dr. King was an
honorary member of the SCMA.

William B. Ardrey, III, M.D., a Rock Hill pediatrician, died in June of this year. A graduate of
The Citadel and Duke University School of Medicine, Dr. Ardrey was an active member of the
SCMA.

William H. Prioleau, Sr., M.D., an honorary member of the SCMA, died on June 1 4, 1 989. Dr.
Prioleau was a clinical professor of surgery at the Medical University of South Carolina. He
graduated from the University of South Carolina and Johns Hopkins University Medical
School.

Frederick F. Adams, Jr., M.D., a retired pediatrician from Spartanburg, died on July 10, 1989.
Dr. Adams was a graduate of the College of Charleston and the Medical University of South
Carolina. He was a disabled member of the SCMA.

Sally B. McCants, M.D., of Columbia, died on July 1 2, 1 989. Dr. McCants graduated from the
University of South Carolina and the Medical College of South Carolina. She was an active
member of the SCMA.

Gerald W. Scurry, M.D., an honorary member of the SCMA, died on July 26, 1989. A retired
general practitioner from Columbia, Dr. Scurry was a graduate of Furman University and the
Medical University of South Carolina.

Those wishing to make Memorials in honor of their deceased colleagues may do so by sending
contributions to the S. C. Institute of Medical Education and Research, P. O. Box 11188,
Columbia, S. C. 29211.

536

The Journal of the South Carolina Medical Association

DO YOU KNOW A TROUBLED PHYSICIAN?

SCMA CAN HELP

TURN PAGE TO LEARN HOW

DO YOU KNOW A TROUBLED PHYSICIAN?

THE SOUTH CAROLINA MEDICAL ASSOCIATION CAN HELP

The SCMA's Physicians' Advocacy and Assistance Committee can and
wants to be the troubled doctor's advocate. The committee views abuse
and addiction to alcohol and other drugs as an illness and deals with it
non-judgmentally , non-punitively and therapeutically.

The program functions as a peer to peer activity, whereby an impaired
physician will undergo evaluation and receive a treatment program
tailored to his or her specific needs in work, family, finances and
community. Voluntary participation results in committee advocacy and a
protective role with the local hospital, medical society. State Board of
Medical Examiners and Drug Enforcement Agency. Voluntary participants
following through with treatment and aftercare are not reported to either
the State Board or any other group or agency.

WHAT IS AN IMPAIRMENT?

The impaired physician has been defined as one who for any reason is
unable to perform professionally at an optimal capacity. That is to say
any disability (impairment) that causes a physician to be unable to do
anything other than his very best. It is felt by this committee that
this definition covers everything from Alzheimer's disease to Alcoholism.
This committee has been asked by the State Medical Association to address
all forms of impairment or disability in regards to the physicians in the
state.

WHAT CAN YOU DO?

The committee would welcome the opportunity to meet with your
concerned groups regarding questions about its activities.

Troubled doctors are usually unable to ask for aid themselves. You
can help them by:

WRITING: Hugh V. Coleman, M.D., Chairman

Physicians' Advocacy and Assistance Committee

South Carolina Medical Association

P. 0. Box 11188

Columbia, SC 29211

(803) 423-3342

CALLING: SCMA Headquarters, (803) 798-6207 or after hours

leave your message at (803) 798-6979

WHAT THE COMMITTEE WILL DO?

Your report will be investigated by a committee member and if
verified, a pair of committee members will contact the impaired
physician and suggest a plan of recovery. Should they fail to recruit
the physician, a second and third team will follow. The physician signs
a contract with SCMA limiting, as mutually agreeable, his or her practice
and enters treatment. A second contract is executed following treatment
for follow-up and assistance in maintaining recovery. At this time a
colleague is also appointed to work with the troubled physician for a
period of up to two years.

CARING AND ANONYMITY ARE KEYS TO THE SUCCESS OF THIS PROGRAM

Auxiliary) Rage

HURRICANE HUGO

Rather than the report on Confluence I which was planned this month, this space is instead being
dedicated to the survivors of the Hugo Disaster and to the many auxilians and their spouses who
responded with tender, loving care to those less fortunate.

The SCMA, the SCMA Auxiliary and SCIMER have established a Hurricane Relief Fund to
provide assistance to the many thousands of Hugo victims in the state. A national appeal has been
made to the members of the AMA as well. Checks should be made payable to SCIMER and mailed
to: Relief Fund, P.O. Box 11188, Columbia, S. C. 29211.

Auxilians are being encouraged to adopt a stricken medical family for a day or a weekend of much
needed “R & R” — a hot meal, a hot shower, a place to do laundry. The Fall Board meeting has been
cancelled and funds which would have been spent on the meeting are being donated to the Hugo
Relief Fund.

Medical families are working together, nurturing each other and others in their communities.
Auxilians are demonstrating that they can respond with their finest efforts in such times of crisis.

Robin Meehan, President

November 1989

539

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The Journal of the South Carolina
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540

The Journal of the South Carolina Medical Association

VOLUME 85

DECEMBER 1989

NUMBER 12

THE SURGICAL-PROSTHETIC
METHOD OF CLEFT LIP AND
PALATE CARE: DEVELOPMENT OF
A COMPREHENSIVE PROGRAM*

ROBERT F. HAGERTY, M.D.

RICHARD C. HAGERTY, M.D.**

WARREN L. GOULD, M.D.**

THE STAFF OF THE CAROLINA CLEFT LIP AND PALATE CENTER***

The Carolina Cleft Lip and Palate Center
was initially organized in 1955 not only for the
treatment of children having this defect, but
also for research into methods of improved
care and for teaching. The initial publication of
the method of the cleft lip and palate care
devised at this clinic appeared in this journal in
1 965. 1 In view of the fact that clefts involve
such important areas of anatomy and function,
a team of specialists is necessary for their care,
including a plastic surgeon, geneticist, pediatri-
cian, otolaryngologist, oral surgeon, orthodon-
tist, dentist, speech pathologist, audiologist,
social worker, and nurse. Since its inception,
this clinic has cared for over 1,300 cleft chil-
dren and has presented its results in national

* From the Carolina Cleft Lip and Palate Center, Roper
Hospital, 316 Calhoun Street, Charleston, S. C. 29401
(address correspondence to Dr. Robert F. Hagerty).

** Department of Plastic Surgery, Medical University of
South Carolina, Charleston, S. C. 29425.

*** Staff members: Virginia H. Edwards; Geraldine D.
Fox, R.N.; Mariana K. Roberts, M.D., ACSW, RSW;
Patricia R. Weathers, M.Aud., CC-A; Rosalyn K.
Monat-Haller, M.Ed., CCC-SLP; Raphael M. Haller,
Ph.D.; Olivia C. Palmer, D.M.D.; Howard F. Vincent,
Jr., D.M.D.; Carlos F. Salinas, D.M.D.; Ernest B. Bass,
Jr., D.D.S.; Richard T. Brock, D.D.S.; Hazel M. Webb,
M.D.; and George W. Bates, M.D.

publications and at international meetings.
Our purpose is to provide a follow-up report.

The cleft defects of the lip and palate are the
most serious of the common congenital abnor-
malities with an incidence of about one in
every 750 births in the USA. The most severe
clefts are by far the most common ones involv-
ing the lip, nose, alveolar ridge (and teeth), the
hard and soft palate and the facial bones. As a
result, the cleft defect will produce alterations
in eating, speech, hearing, dental development,
facial growth and psychosocial maturation,
unless a comprehensive approach for treat-
ment is developed.

For many years (1955 to 1965) the conven-
tional method of treatment was followed at
this center with repair of the lip in the first six
months of life and palatal repair in the second
year. Our results, although excellent by con-
ventional standards of treatment, left much to
be desired. As a result of leaving the palatal
defect open until the second year of life, food
and air readily escaped from the oral cavity
into the nasal cavity, interfering seriously with
the normal processes of eating and speech, in
addition to adding to middle ear infection with
its attendant hearing loss. Lip repair without
support of the divided alveolar segments often

December 1989

549

CLEFT LIP AND PALATE CARE

led to their collapse (medial displacement)
with resultant malocclusion. Surgical repair of
the cleft of the hard palate during this period of
rapid growth frequently resulted in lack of
maxillary and facial growth with exacerbation
of the malocclusion, an abnormally flat facial
profile and retarded psychosocial maturation
(Illustration 1).

In order to avoid these undesirable results
seen in so many patients cared for by the con-
ventional method (both by us and others), an
alternative plan of treatment-care was investi-
gated. With the use of a substitute palate, the
abnormal opening of the hard palate could be
closed with immediate improvement in the
functions of eating, speech and hearing (with
reduced middle ear infection). With fixation of
the substitute palate to the segments of the
upper jaw, their movement could be controlled
and surgical closure deferred until full hard
palatal growth had occurred. As a result, dental
development and occlusion together with fa-
cial growth could be directed along more nor-
mal channels.

From 1965 to 1970, these plans were devel-
oped resulting in the surgical-prosthetic meth-
od as used today. The following protocol
represents the care and steps now followed at
the Carolina Cleft Lip and Palate Center:

six to 1 0 weeks — Insertion of palatal prosthesis
(pin-retained-expandable), sub-total lip
repair,2 bilateral myringotomies with in-
sertion of tubes.

six to nine months — Repair of soft palate (dou-
ble z-plasty3 since 1987), total lip repair,
ear examination.

six to eight years — (Following eruption of the
first permanent molar teeth) removal of
palatal prosthesis, repair of hard palate,
revision of lip and nose as necessary, ear
examination.

If, despite speech therapy, speech does not
develop normally (ie. hypernasality secondary
to velo-pharyngeal incompetence), additional
surgery such as velopharyngoplasty may be
necessary in ages four to six. Bone grafting of
the cleft defects and additional nasal surgery
may also be required.

The clinic meets on alternate Saturday
mornings to bring the patient and family into
direct contact with the team members. Recom-

ILLUSTRATION 1. This is an 18-year-old white female
w ho was born with a cleft of the lip and palate and had her
hard palate closed before age 1. She shows a “dish-faced'’
deformity secondary to deficient growth of the maxilla.

mendations for treatment-care are made by the
appropriate professionals and questions are
answered. Advice and recommendations on
general medical needs, including growth and
development, together with the psycho-social
problems are offered by the pediatrician and
social worker. There is close association with
the Children’s Rehabilitation Services to pro-
vide nursing, social work, nutritional and
speech services throughout the state for eligible
clients in addition to sponsorship of hospital
admissions, dentistry, and orthodontia where
possible. All patients and family members are
encouraged to ask questions in regard to their
care. These are directed to and answered by the
appropriate specialist. Recommendations for
care are openly discussed by the team members
with the family, and support given as needed.
The patient is followed by the team at six-
month intervals with the prosthesis in place

550

The Journal of the South Carolina Medical Association

CLEFT LIP AND PALATE CARE

and then on a yearly basis. With deviation of
the dental arch segments or air leaks, the pros-
thesis may be expanded or modified.

RESULTS

Since 1 970, the surgical prosthetic method of
cleft care has been utilized in 279 cases in our
center. Our experience with eating, speech,
hearing, dental development, facial growth,
psycho-social maturation and genetics is pre-
sented.

A. Eating

With the insertion of the pin-retained ex-
pandable prosthesis as a substitute palate at
about six weeks of age and repair of the soft
palate at about six months, near normal phys-
iological function for eating is restored.

In studies carried out by investigators from
outside our center, a marked improvement in
feeding was noted. Parents of 30 children were
interviewed both prior to and after insertion of
the prosthesis. Prior to insertion, 63 percent
found feeding to be somewhat difficult, after
insertion 87 percent of the patients found feed-
ing to be easy, and the majority finding feeding
to be no more difficult than with their non-cleft
siblings. Loss of food through the nose
dropped from 90 percent to 10 percent.

B. Speech

With the surgical prosthetic method of care,
the hard palatal defect is obturated at six weeks
and near normal palatal physiology obtained
at six months with repair of the soft palate. In
addition, there is marked reduction in the inci-
dence of malocclusion and arch collapse.

Probably the most important aspect of
speech in cleft patients is the quality of the
closure of the soft palate in separating the oral
and nasal cavities to prevent hypernasality.
This center has been active in research in this
field and our studies have shown that this
method of care is superior to the conventional
in Laving fewer speech sound errors. About 80
percent of the patients correctly produced all of
the high pressure sounds which are most often
misarticulated by cleft palate patients. The ma-
jority of the patients developed normal speech
by the age of 12 years. This is attributed to the
superior velo-pharyngeal valving and fewer
dental or dental arch deviations.4- 5

C. Hearing

With conventional treatment, myringotomy
with insertion of tubes is frequently delayed
until lip repair at about six months of age or
may be omitted. With palatal closure post-
poned until the second year of life, food and
fluids are projected into the nasopharynx
adding to the problems of inadequate eusta-
cian tube function. The incidence of middle
ear infection with associated hearing loss is
increased as a result of these delays.

With the surgical-prosthetic treatment, the
early bilateral myringotomy with insertion of
tubes and insertion of the palatal prosthesis
improves the aeration of the middle ear and
decreases the displacement of food into the
nasopharynx. The soft palatal repair and re-
construction of the levator veli palatini mus-
culature is carried out at about six months of
age giving further protection to the naso-
pharynx from contamination of oral contents
and increased eustacian tube function result-
ing in decreased conductive hearing loss.

An analysis of 35 patients treated here utiliz-
ing Puretone Audiometry, speech audiometry,
and tympanometry showed that children less
than five years of age had temporary reduction
in hearing due to middle ear pathologies. This
age group is normally at risk for middle ear
pathologies amongst the general population.
Test results showed a majority (70%) exhibited
normal hearing at six years of age and older
comparing very favorably with the findings in
the general population.

D. Dental Development

The surgical-prosthetic method was de-
signed to secure normal anatomical rela-
tionships. A subtotal lip repair is carried out to
put limited extra-oral pressure on the rela-
tively uncalcified arch segments, and the pros-
thesis inserted to improve or maintain their
relative positions. This approach has resulted
in a greatly improved arch form and dental
occlusion.6 No loss of teeth resulting from the
insertion of the pins has been found.7

These extensive studies utilizing dental im-
pressions, bite plates, and photocopies of the
dental study models with measurements sub-
jected to statistical analysis have shown a
marked improvement in arch form and dental
occlusion when compared to the results ob-

December 1989

551

CLEFT LIP AND PALATE CARE

tained with conventional surgery with no pros-
thetic support.

E. Facial Growth

Facial growth in the unoperated cleft lip and
palate patient is generally within normal lim-
its. In conventional treatment, with repair of
the hard palate in the second year of life within
the period of rapid growth of this structure, a
flat or recessed mid-facial profile is seen in a
large proportion of the postoperative cases. As
a result of delaying surgical closure of the hard
palate until the majority of the maxillary mid-
facial growth is complete, negligible effects on
normal facial development have been seen (Il-
lustration 2, 3, 4). This has been confirmed by
our cephalometric studies utilizing the most
modem and reliable concepts of measurement.8

F. Psycho-social Maturation

The birth of a child with a cleft of the lip and
palate causes an immediate emotional prob-
lem for the parents. They experience shock,
anxiety, depression and guilt. These feelings
and those of rejection are expressed in over-
protection, indulgence and denial.

Since initiation of the surgical prosthetic

ILLUSTRATION 3. A P same patient seventeen (17)
years later after treatment of the bilateral cleft lip and
palate using the prosthetic method.

ILLUSTRATION 2. Female infant born with bilaterial
cleft lip and palate. A P projection.

method the patient has been assured a more
normal and acceptable appearance. With ap-
pearance having such an important impact on
self and others, this method of treatment has
had a significant positive psycho-social impact.

A study carried out by an objective group of
researchers found, with the use of the Vineland
Social Maturity Scale, that the social age for
these patients approximated their chronologi-
cal ages.

ILLUSTRATION 4. Lateral projection of same patient.

552

The Journal of the South Carolina Medical Association

CLEFT LIP AND PALATE CARE

G. Genetics

The majority of the cleft lip and palate cases
are isolated defects and are compatible with
the multifactorial mode of inheritance and rel-
atively low risk recurrence. However, up to 25
percent of the cleft cases represent complex
disorders such as single gene syndromes, ab-
berations or teratogenic defects.

The genetic evaluation of a cleft lip and
palate patient is designed to distinguish the
isolated cleft defects (without associated mal-
formations) from those that represent a genetic
syndrome or a teratogenic defect. This step is
of utmost importance to provide proper ge-
netic counseling for the parents of an affected
child as well as for the treatment modifications
and results expectations regarding a given
case.9

CONCLUSION

The surgical-prosthetic method is designed
to secure near normal anatomy and function at
the cleft site as early as possible with minimal
limitations to optimal development. As com-
pared with the results of conventional treat-
ment, marked improvements have been seen
in eating, speech, hearing, dental development,
facial growth and psychosocial maturation.10

The possible complications associated with
a prosthesis of this type such as irritation of the
underlying mucosa by trapped food particles,
osteomyelitis, sinusitis, and loss of teeth have
not been seen. Lack of growth of the maxilla
with the resulting flat or recessed facial profile
with severe malocclusion now is a rarity. This
tragedy is all the more serious in that these
defects must be endured through the most
important years of development, until full
growth is attained before the necessary exten-
sive and expensive corrective surgery can be
carried out. In light of this frequent complica-
tion of conventional cleft surgery, the multiple
limited operative procedures of the surgical-
prosthetic method, including replacement of
the prosthesis to obtain complete expansion or
obturation, are a satisfactory alternative (Il-
lustration 5).

This method of care has now been utilized
by cleft palate centers in four university medi-
cal schools and by numerous plastic surgeons
in private practice. □

►—

ILLUSTRATION 5. Photograph of the prosthesis in
place over the maxillary mold showing how the prosthesis
fits in position.

ACKNOWLEDGEMENTS
We wish to thank the National Institute of Dental Re-
search for its support of many of these studies.

This research was supported by Grant DE045 1 7-02 from
the National Institute of Dental Research.

REFERENCES

1. Hagerty, Robert F., Mylin, Willis K., Hess, Donald A.
The pin-retained expandable prosthesis in cleft palate
treatment. J. S. C. Med. Assoc. 61:221-229, August
1965.

2. Hagerty, Robert F. Unilateral cleft lip repair. Surg.
GYN Obst. 106:119-122, January 1958.

3. Furlow, L. T„ Jr., M.D. Cleft Palate Repair by Double
Opposing Z-Plasty. Plast. Reconst. Surg. 78 (6):724-
736, 1986.

4. Coston, G. N., Hagerty, R. F., Jannarone, R. J.,
McDonald, V., Hagerty, R. D. Levator muscle recon-
struction: Resulting velopharyngeal competence.
Plast. Reconstr. Surg. 77:911-915, 1986.

5. Haller, R. M. Speech Results in the Surgical-Prosthetic
approach to cleft palate management at the Carolina
Cleft Lip and Palate Center, Sixth Annual Cleft Palate
Symposium, Richland Memorial Hospital, Columbia,
S. C., April 1986.

6. Hagerty, Robert F., Mylin, Willis K. Facial growth and
arch symmetry in the surgical prosthetic treatment of
cleft lip and palate. Plast. Reconstr. Surg. 68(5):628-88,
November 1981.

7. Jorgenson, R. J., Salinas, C. F., and Hirsh, H. The Pin-
Retained Palatal Prosthesis and Its Influence on the
Dentition. J. Dent. Res. 58:1570-1571, 1979.

8. Hagerty, R. F., Youmans, C. P., D.M.D., Hagerty,
R. C. The midfacial skeletal profile in late repair of the
hard palate. Proceedings of the International Cleft
Palate Association, September 1985, Monaco.

9. Salinas, C. F., Editor. Craniofacial Anomalies: New
Perspectives. March of Dimes Birth Defect Founda-
tion. Birth Defects: Original Article Series 18(1) New
York: Alan R. Siss, Inc. 1982.

10. Hagerty, R. F., Mylin, W. K. Aesthetics and Function
in Cleft Lip and Palate Care, The Art of Aesthetic
Plastic Surgery. Little, Brown, and Company, 463-470,
1989.

December 1989

553

IDENTIFICATION AND INTERVENTION
FOR ALCOHOL ABUSE

STEPHEN HOLT, M.B.*

Studies on the prevalence of alcohol abuse in
hospital and private practice indicate that
many patients who have drinking problems
may pass unrecognized.1'4 Problem drinkers
are ubiquitous in clinical practice and evidence
has accumulated that physicians may be expe-
riencing a “tip of the iceberg” phenomenon. If
early identification of alcohol abuse is an ap-
propriate intervention for the alcohol prob-
lem, why do physicians generally avoid, forget
or miss the diagnosis? This paper will examine
some of the aspects of screening for alcohol
abuse that have precluded its general introduc-
tion and highlight the need for systematic case
identification and brief intervention in select-
ed patient populations.

CRITICAL ISSUES IN SCREENING
FOR ALCOHOL ABUSE

Physicians are tired of being told that they
fail to detect the “alcoholic.”5 Pause a moment
and consider those factors that confound diag-
nostic acumen. Careful study of the spectrum
of drinkers depicted in Figure 1 may provide
some insight. For approximately three quar-
ters of the population of North America, alco-
hol is not a problem and its controlled use may
provide advantages such as the enhancement
of the appreciation of food and some social
functions. There is a small group (approx-
imately five percent) of adult males who show
major symptoms of alcohol dependence but
there is a much larger group who constitute
“problem drinkers” (Figure 1). The problem
drinker is amenable to identification and inter-
vention at a stage in his or her illness where
irreversible disease is absent, social stability
can be retained and prognosis for recovery is
favorable1’ 2 (Figure 2). Clearly, the medical
profession must accept some responsibility for
confronting alcoholism, but by what method?

* Department of Medicine, University of South Carolina
School of Medicine, 2 Richland Medical Park, Suite 506,
Columbia, S. C. 29203.

FIGURE 1

FIGURE 1. This diagram depicts the expected spectrum
of drinking habits in North American society. Reproduced
from “The Alcohol Clinical Index,” Skinner HA and Holt
S, 1987, published by the Addiction Research Foundation,
Toronto, Canada.

FIGURE 2

FIGURE 2. Figure 2 demonstrates that the morbidity pro-
file of alcohol abuse changes with the duration of excessive
drinking and highlights the importance of the development
of sociobehavioral disorders in early problem drinkers.
Reproduced from “The Alcohol Clinical Index,” Skinner
HA and Holt, S, 1987, published by the Addiction Re-
search Foundation, Toronto, Canada.

Early identification

Diagnosis

Usual focus of
treatment and research

Area of overlap

Duration of excessive drinking

Short

Long

554

The Journal of the South Carolina Medical Association

ALCOHOLISM

The detection of early problem drinkers will
not occur efficiently in a setting where medical
information is recorded at the expense of so-
ciobehavioral factors.1’ 2’ 6- 7 The physical con-
sequences of alcohol abuse may only become
apparent after a prolonged period of hazardous
drinking (Figure 2) and early problem drinkers
are frequently devoid of any physical findings
on clinical examination.7’ 8 Medical education
has focused on defining the biological conse-
quences of excessive drinking without stress-
ing the importance of psychological and social
factors that can establish an early diagnosis.7
This educational process breeds a type of prac-
tice that explains, in part, why medical and
social sciences literature is replete with obser-
vations that alcohol abusers are misdiagnosed,
missed or ignored.1'4- 9
The primary care physician or nurse practi-
tioner is often in a good position to identify
excessive drinkers who do not consider them-
selves “alcoholic.”9 A promising basic strategy
is to identify and intervene with brief counsel-
ling before the patient has developed major

TABLE 1

This algorithm could be utilized in clinical practice in the
routine mangement of patients with alcohol problems. Re-
produced from “The Alcohol Clinical Index,” Skinner HA
and Holt, S, 1987, published by the Addiction Research
Foundation, Toronto, Canada.

symptoms of alcohol dependence8 (Table 1).
The cumulative impact of this approach
should result in a large number of patients
undergoing low-cost intervention at early
stages of problem drinking when outcome is
potentially favorable.1-3 Unfortunately, accep-
tance of this approach has been hindered in
several ways. Physicians in primary care prac-
tice have complained about what they consider
unfair systems of reimbursement which tend
to reward the performance of “procedures” at
the expense of time-intensive cognitive ac-
tivity, such as history taking and counselling.
This has resulted in a major financial gap be-
tween technology orientated and time-inten-
sive medical care. This situation provides a
major disincentive for early intervention pro-
grams for alcohol problems which may repre-
sent an unattractive financial proposition for
the physician in private practice in the U.S.A.
The economics of medicine may play a major
role in the failure of the introduction of sec-
ondary prevention for alcohol problems and
financing remains a key determinant of the
lack of general acceptance and utilization of
such programs.1- 2’ 8

HOW SHOULD DETECTION OCCUR?

A number of factors appear to be important
for the physician to adopt secondary preven-
tive strategies in clinical practice. The simplest
clinical measure would be to take an adequate
drinking history in everyday practice.8’ 10 This
routine act may make more impact than any
hierarchical progression through diagnostic in-
struments of increasing sophistication.1’ 2 Phy-
sician alertness, suspicion and tact in a simple
direct interview would often uncover the “oc-
cult” problem drinker without alienation or
compromise of the “patient-doctor” rela-
tionship. This approach should perhaps super-
sede any consideration of validity or reliability
of the instruments that are available to detect
alcohol abuse.

The more promising biochemical markers of
excessive drinking, such as gamma-glutamyl
transpeptidase (GGT) and mean corpuscular
volume (MCV), have only moderate diag-
nostic sensitivity in ambulatory populations,
and these tests may return to normal following
a short period of abstinence or a significant
reduction in alcohol consumption.2’ n- 12 Re-

December 1989

555

ALCOHOLISM

cent studies have shown that diagnostic ac-
curacy can be enhanced by the combined use of
historical data and laboratory tests.11’ 12 In a
comparison of laboratory tests and question-
naire data, the best laboratory test detected
only a third of alcoholics, whereas three brief
interviews each identified nine out of ten
alcoholics.12

Given these findings, one might question
why a brief diagnostic questionnaire such as
the CAGE13 is not given routinely as part of a
diagnostic medical history? The CAGE is an
acronym derived from questioning whether
the patient feels a need to Cut down on drink-
ing, is Annoyed by criticism of his or her drink-
ing, feels Guilty about drinking, and
even drinks first thing in the morning
(Eye-opener).13 It is increasingly recognized
that the systematic use of brief questionnaires,
consideration of laboratory tests2 (e.g., GGT,
MCV) and recording of blood alcohol levels
among selected patients14 would result in the
identification of many patients who misuse
alcohol.

DIAGNOSTIC INSTRUMENTS

Key instruments for the diagnosis of alco-
holism that incorporate medical data include
the National Council on Alcoholism (NCA)
criteria,15 the Michigan Alcoholism Screen
Test (MAST),16 the Munich Alcoholism Test
(MALT),17 Alcohol Use Disorder Identifica-
tion Test (AUDIT)18 and the Alcohol Clinical
Index (ACI). 19-20 Although the NCA criteria
provide a comprehensive list of main physical,
social and psychological sequelae of alco-
holism, many of these criteria appear to be
redundant for identifying the alcoholic patient.
In one study, there was no significant dif-
ference between alcoholic and control patients
according to 38 of 86 of the NCA criteria.21 The
MAST is a widely used instrument containing
25 items that refer to the medical, social, intra-
personal and legal consequences of problem
drinking.16 The total MAST score classifies
patients along a continuum according to the
degree of alcohol misuse.16 The test can be
completed expeditiously by interview or by
self report, and encouraging results on its relia-
bility and validity have been observed.1 How-
ever, patient denial may be a problem for the
MAST.1

By including objective data, such as clinical
signs and laboratory findings, that indicate the
presence of alcohol-related diseases, it may be
possible to corroborate interview and self-
reported data, thereby obtaining a more accu-
rate assessment of alcohol abuse.1’ 2’ 17- 19’ 20
This approach was used by Feuerlein and asso-
ciates17 to develop the MALT. This test con-
tains two sections: part A is completed by the
clinician, and part B, which contains 24 items
pertaining to alcohol abuse and its adverse
social and somatic effects, is completed by the
patient. Although the MALT has produced en-
couraging results, it seems that the medical
items contained in part A are sensitive only to
disorders that develop in the later stages of
alcohol abuse.7’ 8 Nevertheless, this test is a
reasonable prototype of short tests that com-
bine medical and psychosocial indicators of
alcohol abuse.7

The common association of alcohol abuse
with trauma14’ 22 has led to the development of
the Trauma Scale which is a diagnostic instru-
ment that may have widespread appeal to a
physician because it is relatively unobtrusive
and utilizes biomedical data almost ex-
clusively. This scale was developed in a study5
involving 68 ambulatory patients with known
alcohol problems and 68 social drinkers
matched for age and sex. A short questionnaire
about the patients’ history of trauma was
found to identify seven out of 10 subjects with
drinking problems. In contrast, abnormal val-
ues for gamma-glutamyl transferase, mean cor-
puscular volume, or high density lipoproteins
had only moderate sensitivity (26% to 40%) for
identifying alcohol problems in these subjects
but excellent specificity (88% to 99%) for ruling
out cases. This study suggests that a brief his-
tory of trauma is valuable for the early detec-
tion of problem drinking in ambulatory
populations,5’ 20 in contrast to laboratory tests,
which appear to have reasonable sensitivity
with more chronic “alcoholics.” The Trauma
Scale5 provides a diagnostic strategy, for de-
tecting alcohol problems, that could be readily
implemented in general clinical practice.

The ACI was developed in a study19 that was
designed specifically to determine reliable in-
dicators of alcohol abuse. In this study,19 a
comprehensive set of clinical and laboratory
information1-2 was acquired from three groups

556

The Journal of the South Carolina Medical Association

ALCOHOLISM

of subjects with a wide range of drinking histo-
ries. Findings from clinical examination pro-
vided greater diagnostic accuracy than labora-
tory tests for detecting alcohol abuse. 19 Logistic
regression analysis produced an overall ac-
curacy of 85-91% for clinical signs, 84-88% for
items from the medical history, and 71-83% for
laboratory tests in differentiating the three
groups. Further analyses showed 17 clinical
signs and 1 3 medical history items that formed
a highly diagnostic instrument (the ACI) that
could be used in clinical practice.20 Despite
recent emphasis in biomedical literature on
the laboratory diagnosis of alcohol abuse,
these findings imply that simple clinical mea-
sures seem to provide better diagnostic
accuracy.19’ 20

The findings, during the development of the
ACI, underscore the value of selected items
from the medical history and clinical signs,
which can be combined to form an objective
index. The AUDIT is a similar instrument to
the ACI that was developed by a working party
of the World Health Organization.18 The
AUDIT can be utilized in a variety of primary
care settings, and it consists of the core AUDIT
which is a brief interview that may be incorpo-
rated into a medical history and an optional
component, the clinical AUDIT which con-
sists of two interview items, a brief physical
examination and a laboratory test.18 However,
unlike the ACI,19’ 20 the AUDIT18 was derived
empirically and not by statistical methodology
based upon data collected in a population with
a wide spectrum of drinking habits.19’ 20

Previously, incomplete knowledge of the di-
agnostic power of specific clinical items has
prevented firm recommendations about indi-
cators of excessive drinking. The ACI19> 20
could be applied routinely during clinical ex-
amination and corroboration could be
achieved by a brief questionnaire on alcohol
problems such as the MAST or CAGE, as well
as by laboratory tests including mean cor-
puscular volume and glutamyl transferase ac-
tivity.20 This practical strategy (Table 1) could
make significant inroads on identifying drink-
ing problems that often remain undetected in
medical practices.8

Biological markers of excessive drinking
have enticed the would-be “screeners” but as
yet no single laboratory test on body fluids has

shown acceptable sensitivity during screen-
ing.2 Small reductions in specificity during
screening are translated into unwanted false
positives and significant misclassification.2
Low cost screening technology should be fur-
ther explored in clinical practice. The use of
breathalyzer instruments14’ 23 or microcom-
puters16 in selected contexts hold considerable
promise in this regard. Emerging biological
tests, especially assays of body fluids, that
promise of superior diagnostic ability must be
viewed with caution or healthy skepticism.

QUESTIONABLE EFFECTIVENESS
OF INTERVENTIONS?

Alcohol abuse defies some of the axioms of
preventive medicine.1’ 2 It is inappropriate to
detect a disease for which effective treatment is
lacking. This raises a serious question. Do we
at this time have interventions that can signifi-
cantly alter the course of alcohol abuse? The
available evidence is promising but not con-
vincing. A consistent finding from research on
the treatment of alcohol abuse is that patient
characteristics have a greater effect on the out-
come than the kind of treatment given.1 If we
lack interventions that are powerful enough to
alter the course of alcohol abuse, then the early
identification of causes may yield meager re-
sults.1 In addition, the mere identification or
labelling of patients can produce deleterious
effects.1

Consensus is lacking on definitions of the
alcohol related disorders that need to be identi-
fied and alcohol abuse does not present a read-
ily recognizable, clear cut syndrome.1’ 2’ 14* 19’ 20
Undoubtedly, one explanation for the lack of
precise definitions of alcohol abuse or “alco-
holism” is the complexity of disorders that are
determined either directly or indirectly caused
by alcohol abuse. The traditional concept of
alcoholism as a single specific disorder has
failed to adequately represent the diverse and
multifaceted problems related to drinking with
the result that the multiple-syndrome concept
is gaining ascendancy.1’ 24 However, consider-
able work is needed to refine the definitions of
hazardous drinking and the associated alcohol
related syndromes.1’ 2’ 18

NEED FOR INNOVATIVE APPROACHES
TO TREATMENT (INTERVENTION)

The intensity of present treatment methods,

December 1989

557

ALCOHOLISM

which are aimed primarily at rehabilitation,
may be unnecessary for helping those at an
early stage of alcohol abuse. There are indica-
tions that a lower cost intervention, consisting
of assessment, brief counselling and follow-up,
can yield results that are comparable to those
of traditional inpatient and outpatient pro-
grams for alcohol abuse.25 This basic interven-
tion could be readily adapted to clinical
practice and general hospitals.8 Although fur-
ther clinical investigation is needed, it appears
that a brief advice session, given by physicians
in the earlier stages of excessive drinking,
could have the widespread impact of curtail-
ing the prevalence of alcohol related
disabilities.1’ 2’ 6- 8

In addition to low cost clinical interven-
tions, another approach is a large scale preven-
tion program, like the heart disease prevention
program of Stanford University in Palo Alto,
California.26 In this study, involving three
communities, intensive instructions given to
individuals identified as being at high risk for
heart disease significantly reduce such phys-
iologic indices of risk such as blood pressure,
relative weight and serum cholesterol concen-

REFERENCES

1. Skinner HA, Holt S, Israel Y. Early Identification of
Alcohol Abuse: Critical Issues and Psychosocial Indi-
cators for a Composite Index. Canadian Medical Asso-
ciation Journal 124:1141-1152, 1981.

2. Holt S., Skinner HA, Israel Y. Early Identification of
Alcohol Abuse: Clinical and Laboratory Indicators.
Canadian Medical Association Journal 124:
1279-1294, 1981.

3. Pearson WS: The “Hidden” Alcoholic in the General
Hospital. A Study of “Hidden” Alcoholism in White
Male Patients Admitted for Unrelated Complaints.
North Carolina Medical Journal, 3:6-10, 1962.

4. Rubington E: The Hidden Alcoholic. Quarterly Jour-
nal of Studies on Alcohol 33:667-683, 1 972,

5. Skinner HA, Holt S, Schuller R, Roy J, Israel Y.
Identification of Alcohol Abuse Using Laboratory
Tests and a History of Trauma. Annals of Internal
Medicine 101:847-851, 1984.

6. Holt S, Skinner HA, Israel Y. Confronting Alco-
holism. Canadian Medical Association Journal
126:351-352, 1982.

7. Skinner HA, Holt S, Allen BA, Haakonson NH. Cor-
relation between medical and behavioral data in the
assessment of alcoholism. Alcoholism: Clinical and
Experimental Research 4:371-377, 1980.

8. Skinner HA, Holt S. Early intervention for alcohol
problems. Journal of the Royal College of General
Practitioners 33:787-791, 1983.

tration.26 This finding suggests that mass me-
dia educational campaigns directed at entire
communities can be effective in reducing the
risk of cardiovascular disease. Although a sim-
ilar program may prove successful in reducing
the prevalence of alcohol abuse, especially for
individuals identified as being at risk, research
to date indicates that influencing patients’ at-
titudes toward alcohol use will not necessarily
change their behavior to healthier patterns.27

SUMMARY

Early diagnosis of alcohol abuse with brief
intervention, in appropriate clinical settings,
offers great promise for the reduction of the
prevalence of alcohol related morbidity and
mortality.1- 2’ 19- 20 Secondary prevention of
alcohol abuse offers promise for a reduction in
alcohol related mortality and morbidity that
cannot be readily achieved in an acceptable
manner with primary preventive or conven-
tional rehabilitative measures. A concerted
medical effort, using simple diagnostic meth-
odology16’ 18-20 to find cases and offer advice
about drinking,8 will undoubtedly result in a
positive impact on alcohol problems. □

9. Wilkins R. H. The hidden alcoholic in general prac-
tice: a method of detection using a questionnaire. Elek
Science, London, England, 1974.

10. Smith M, Vasudeva R, Skinner HA, Holt S. Computer
Assessment of Lifestyle in a Gastroenterology Clinic.
American Journal of Gastroenterology 9:1065, 1988.

1 1 . Chick J., Kreitman N, Plant M. Mean cell volume and
gammaglutamyl transpeptidase as markers of drinking
in working men. Lancet i: 1249- 1251, 1981.

12. Bernadt MW, Munford J, Taylor C, Smith B. Murray
RM. Comparison of questionnaire and laboratory
tests in the detection of excessive drinking and alco-
holism. Lancet i:325-328, 1982.

13. Ewing J A. Detecting Alcoholism: The CAGE Ques-
tionnaire. Journal of the American Medical Associa-
tion 252: 1905- 1907, '1984.

14. Holt S, Stewart IC, Dixon JM, Elton RA, Taylor TV,
Little K. Alcohol and the emergency service patient.
British Medical Journal 281:638-640, 1980.

1 5. National Council on Alcoholism, Criteria Committee:
Criteria for the Diagnosis of Alcoholism. American
Journal of Psychiatry 129:127-135, 1972.

16. Selzer ML. The Michigan Alcoholism Screening Test:
the Quest for a New Diagnostic Instrument. American
Journal of Psychiatry 127: 1653-1658, 1971.

17. Feuerlein W., Ringer C, Kufner H, Antons K. Diag-
nose des Alkoholismus der Munchner Alco-
holismustest (MALT). Munchich Medizinisch
Wochenshrift 119:1275-1282, 1977.

558

The Journal of the South Carolina Medical Association

ALCOHOLISM

18. Babor, TF, Weill J, Treffardier M, Benard JY. Detec-
tion and diagnosis of alcohol dependence using the Le
Go grid method. In: Chang, N.C. and Chao, H.M.
(Eds.) Early Identification of Alcohol Abuse. Research
Monograph No. 17. Rockville, MD: National Institute
on Alcohol Abuse and Alcoholism. DHHS Pub. No.
(ADCM) 85-1258, 1985.

1 9. Skinner HA, Holt S, Sheu WJ, Israel Y. Clinical Versus
Laboratory Detection of Alcohol Abuse: the Alcohol
Clinical Index. British Medical Journal 292:
1703-1708, 1986.

20. Skinner HA, Holt S. The Alcohol Clinical Index, Man-
ual and Questionnaires Addiction Research Founda-
tion of Ontario. Toronto Publications, 1987.

21. Ringer C, Kufner H, Antons K, Feuerlein W: The
N.C.A. Criteria for the Diagnosis of Alcoholism. An
Empirical Evaluation Study. Journal of Studies on
Alcohol 38:1259-1273, 1977.

22. Israel Y, Orrego H, Holt S, MacDonald DW, Meema
HE. Identification of alcohol abuse: thoracic fractures
on routine chest X-rays as indicators of alcoholism.
Alcoholism (NY) 4:420-2, 1982.

23. Holt S. Observations on the dependence of alcohol
absorption on the rate of gastric emptying. Canadian
Medical Association Journal 124:267-277, 1981.

24. Skinner HA, Allen BA. Alcohol dependence syn-
drome: measurement and validation. Journal of Ab-
normal Psychology 91:199-207, 1982.

25. Edwards G, Orford J. A Plain Treatment for Alco-
holism. Proc R Soc Med 70:344-348, 1977.

26. Farquhar JW, Maccoby N, Wood PD, Alexander JK,
Breitrose H, Brown BW Jr, Haskell WL, McAlister AL,
Meyer AJ, Nash JD, Stem MP. Community education
for cardiovascular health. Lancet 1:1 192-1 195, 1977.

27. Goodstadt MS. Alcohol and Drug Education: Models
and Outcomes. Health Education Monograph
6:263-279, 1978.

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Charlotte, NC 28210.

December 1989

559

RECURRENCE OF NODE-NEGATIVE
BREAST CANCER IN PATIENTS TREATED
IN A COMMUNITY HOSPITAL*

BETTY M. HAHNEMAN, M.D., M.P.H.**

SHIRLEY J. THOMPSON, Ph.D.

WILLIAM H. BABCOCK, M.D.

SUSAN SALTERS, B.A., C.T.R.

Standard treatment of primary breast cancer
includes surgical removal of the tumor, along
with some or all of the axillary lymph nodes. In
women who are node positive, that is, in whose
nodes malignant cells are found, microscopic
spread of tumor to other areas of the body is
assumed to have occurred, and adjuvant hor-
monal and/or antineoplastic drug therapy is
usually recommended.

Since a majority of patients who are node
negative do not have recurrence of tumor,
standard management has been to recommend
no adjuvant therapy for these women, and
none was recommended for routine use by the
most recent NIH Consensus Conference
( 1 985). 1 However, in May, 1988, a brief notice
termed a “Clinical Alert” was sent from the
National Cancer Institute to physicians in the
United States who treat breast cancer. This
communication stated that, in the node nega-
tive patient, adjuvant hormonal or cytotoxic
drug therapy “represent credible therapeutic
options worthy of careful attention.”2 The
Clinical Alert has been generally interpreted as
recommending that adjuvant treatment be
considered for all node negative breast cancer
patients. The recommendation was based on
the results of clinical trials which had not yet
been published, but were briefly summarized
in the Clinical Alert; they have been published
subsequently.3’ 4’ 5> 6

There is controversy in the Oncology com-
munity with regard to the appropriateness of

* From the Department of Epidemiology and Bio-
statistics, School of Public Health, University of South
Carolina (Drs. Hahneman and Thompson) and the
Baptist Medical Center Columbia (Dr. Babcock and
Ms. Salters), Columbia, S. C.

** Address correspondence to: Betty M. Hahneman, M.D.,
600 Woodrow Street-J, Columbia, S. C. 29205.

systemic treatment in node-negative patients.
The emergence of this issue has made it impor-
tant to identify those patients who are at high
risk of recurrence, that is, those who are most
likely to be benefited by adjuvant therapy, and
in whom the potential benefit might justify the
risks and costs of such treatment.

Physicians at Baptist Medical Center Co-
lumbia (BMCC) who are involved in the man-
agement of patients with breast cancer pro-
posed that data from the Medical Center’s
Cancer Registry be used to investigate that
institution’s experience with node-negative
breast cancer.

The present study addresses two questions:

1 . What is the rate of recurrence of breast
cancer in patients who are node-negative at the
time of first treatment?

2. What, if any, clinical factors are associ-
ated with recurrence?

METHODS

Data for this study were obtained through
the BMCC tumor registry. The study popula-
tion consisted of women who were diagnosed
as having carcinoma of the breast during the
years 1 979 through 1 983, and who were treated
at BMCC. Criteria for inclusion were:

1 . Histologic diagnosis of carcinoma of the
breast.

2. Axillary nodes removed at the time of
diagnosis and found to be negative for tumor
on histologic examination. (Due to the retro-
spective nature of the study, the number of
nodes examined in each specimen could not be
determined.)

3. Initial therapy (all or part thereof) carried
out at BMCC.

4. No evidence of metastatic disease at the
time of diagnosis.

560

The Journal of the South Carolina Medical Association

BREAST CANCER

5. No evidence of inflammatory carcinoma.

6. No prior diagnosis of breast cancer and
no prior mastectomy.

Appropriate records were abstracted for in-
formation on age, menopausal status, TNM
stage, size, histologic type, presence or absence
of estrogen receptors in the primary tumor,
surgical procedures performed, radiation or
chemotherapy administered as part of the ini-
tial treatment and site of first tumor recur-
rence. Women 50 years and over were assumed
to be postmenopausal and those 49 or less to be
premenopausal, when clinical records did not
indicate otherwise. Tumor size was defined as
maximum diameter in centimeters as stated by
the pathologist on the written report of the
tissue examination.

Tumors were classified as ductal or lobular
in type: duct included papillary, comedo,
mucinous, scirrhous, or any other type of
ductal origin. Tumors were also classified as
either invasive or in situ; all diagnoses were
taken from the examining pathologist’s report.

TNM stage was determined using criteria in
the Manual for Staging of Cancer, 2nd Edition,
the standard for use in all approved cancer
registries in the United States.

Estrogen receptor status was defined as lev-
els of greater than 10 femtomoles of receptor
per gram of cytosol protein or a report of
“positive” or “negative” on the clinical record.

Standard annual follow-up procedures, as
required for Cancer Registries approved by the
Commission on Cancer of the American Col-
lege of Surgeons were used by the Registry to
determine time in months to recurrence,
death, last follow-up, or loss to follow-up.

Frequency tables were constructed to evalu-
ate the data with calculation of means and
standard deviations when appropriate. Chi-
square statistics were employed to test for sig-
nificance of associations between clinical fac-
tors and tumor recurrence.

RESULTS

Of the 786 women seen at BMCC for pri-
mary diagnosis or treatment of breast cancer
during the five-year study period, 238 (30.3
percent) were identified as node-negative.

Table 1 shows that of the 238 node-negative
patients, 1 9, or eight percent, died of other or
unknown causes or were lost to follow-up;

TABLE 1

Outcomes for Node Negative Breast Cancer Patients
Baptist Medical Center, 1979-1983

Number

Percent

Status:

Recurrence

19.3

No recurrence

173

72.7

Died, other

3.8

Died, unknown cause

2.1

Lost to follow-up

2.1

Total

238

100.0

Follow-up

(in months):

Mean 68.6 months; S.D. 28.9 months

Site of

Local-regional

34.1

first

Bone

31.8

metastasis:

Liver

6.8

Lung

6.8

Brain

2.3

Parotid gland

2.3

No information

Two patients with distant metastases had tumors found at

an additional site upon evaluation at time of first metasta-

sis: 1 to lung,

1 to brain.

these patients were not included in the analy-
ses. Follow-up post diagnosis averaged 5.7
years.

The study population is about evenly di-
vided among the age groups under 50, 50-60,
60-70 and over 70 (Table 2). The patients are
predominantly white, postmenopausal, with
ductal type, infiltrating tumor histology. Just
over 25 percent had tumors of one centimeter
or less, and nearly two-thirds (64.6 percent)
had tumors two centimeters or less in diameter.

Estrogen receptor tests were performed for
two-thirds of the patients, but results were not
available in all cases. More than half of the
estrogen receptor results which were obtained
were positive. Surgical treatment in over 90
percent was modified radical mastectomy;
nearly half received radiation therapy, only
two received adjuvant chemotherapy.

Chi-square tests were used to determine if
tumor recurrence was associated with age,
menopausal status, stage, tumor size, and es-
trogen receptor status. Of these characteristics,
only tumor size showed a significant associa-
tion with tumor recurrence. Table 3 presents
the results by tumor size category; for each
increase in size category, there is approx-
imately a 10 percent increase in rate of tumor
recurrence. Expressed in terms of relative

December 1989

561

BREAST CANCER

TABLE 2

Characteristics of Node-Negative Patients
(N=238)

Number Percent

Age:

<40 years

7.1

40-49 years

19.7

50-59 years

26.5

60-69 years

23.5

>70 years

23.1

Mean 58.5 years; s.d.

13.2

years

Race:

White

214

90.3

Black

9.3

Other

0.4

Missing

Menopause:

Premenopause

24.7

Postmenopause

179

75.2

Histology:

Ductal

216

90.8

Lobular

9.2

Infiltrating

226

95.0

In situ

5.0

Size:

1 cm. or less

25.6

(maximum

1.1-2 cm.

39.0

diameter)

2.1-3 cm.

25.6

>3 cm.

9.9

none recorded

Stage:

5.4

134

60.4

34.2

missing

Estrogen:

Positive

56.7

(receptor

Negative

43.3

status)

not done/unknown

Mastectomy:

Modified radical

218

91.6

Radical

5.0

Segmental

3.4

Radiation:

Done

101

42.4

Not done

137

57.6

risks, patients with tumors of 1 . 1 to 2 cm in size
are approximately twice as likely to experience
recurrence than patients with smaller tumors;
patients with tumors greater than 3 cm are four
times more likely to have tumor recurrence
than patients with tumors less than 1 cm. Also
shown in Table 3 is the analysis of recurrence
by TNM Stage, where a significant association
was not demonstrated; the p value of 0.08,
however, approaches significance and a larger
number of cases would likely clarify the asso-
ciation.

When radiation therapy as part of initial
treatment was examined, no association with
recurrence was seen, even when tumor size was

controlled (Table 3). Analysis of radiation
therapy for association with site of first recur-
rence (local-regional versus systemic) pro-
duced some evidence of radiation having a
protective effect against local-regional recur-
rence, but the p value of 0.07 did not reach the
desired level of significance. There were only
37 patients on whom information as to site of
first recurrence was available. Larger numbers
of patients are needed to adequately evaluate
the effect of radiation therapy on recurrence;
however, this may be of interest since many
patients receiving radiation were thought to be
of increased risk of local recurrence.

A number of studies have been published
showing recurrence rates in patients with
node-negative breast cancer; most cite recur-
rence rates in the range of 20 to 30 percent. The
untreated control groups of the studies upon
which the Clinical Alert was based 3> 4> 5> 6 show
recurrence rates of 23 to 31 percent. A large
series published by Nemoto, et al.7 represents
the results of national survey taken by the
American College of Surgeons; their recur-
rence rate of 1 9 percent is probably more repre-
sentative of community practice than are the
others, which are based on groups of patients
selected for clinical trials.

Table 4 compares the study population at
BMCC with the untreated control groups of the
studies upon which the Clinical Alert was
based, with regard to several characteristics. It
is evident that the BMCC patients were older
(and, in particular, had a much higher propor-
tion of women over 70 years of age), had
smaller tumors, and had a lower recurrence
rate, despite a longer follow-up. It is interesting
to note that the recurrence rate of 21 percent in
this series is very close to the 19 percent rate
reorted by Nemoto et al. in the large national
survey series.

DISCUSSION

This study has documented a recurrence rate
of 21 percent in patients treated at Baptist
Medical Center Columbia for node-negative
breast cancer, which is less than that seen in the
untreated control groups of the studies on
which the NCI’s Clinical Alert was based; the
BMCC population also differs from these
groups as to age and tumor size.

Given the differing population characteris-

562

The Journal of the South Carolina Medical Association

BREAST CANCER

TABLE 3

Recurrence by Tumor Status in Node Negative Breast Cancer Patients

Percent

Relative

Status

Recurrence

Risk

Tumor Size
1 cm. or less

9.3

1.0* *

1.1-2 cm.

21.8

2.3

2.1-3 cm.

28.9

3.1

>3 cm.

38.1

4.1

Chi-square=9.716, p =

.02 (3 df)

TNM Stage
Stage I

18.9

1.0*

Stage II

30.0

1.6

Chi-square = 3. 13, p =

.08 (1 df)

Tumor Size

Radiation

< = 2 cm.

Yes

15.7

17.3

1.2**

>2 cm.

Yes

36.1

27.0

Chi-square = .05, p=.82 (3 df)

Totals vary due to missing values.

* Referent group

** Risk of recurrence with radiation therapy controlling for tumor size.

tics, and considering the small differences in
disease-free survival demonstrated in the four
Clinical Alert studies, the decision as to
whether to recommend adjuvant treatment for
any given patient with node negative breast
cancer remains a difficult one. On the basis of
the findings presented here, tumor size appears
to be the only variable significantly associated
with recurrence rate in the BMCC population.

The increased use of mammographic screen-
ing in community practice should increase the
proportion of patients in the most favorable
group, those with tumors under 1 cm. in diam-
eter. It is also quite possible that one or a
combination of the new laboratory tests now
being investigated will be of help in making

treatment recommendations. Additionally,
the development of more effective and less
toxic treatments could improve the potential
benefits of adjuvant therapy to patients with
node-negative breast cancer.

Given that the characteristics of the patients
in this study differ from those on which the
Clinical Alert was based, it would be of interest
to examine factors associated with recurrence
among all women in South Carolina diagnosed
with node-negative breast cancer. Certainly
larger samples of patients would enhance the
validity and usefulness of the current analysis.
The currently proposed statewide tumor regis-
try would allow a more complete evaluation of
these and other cancer issues. □

December 1989

563

BREAST CANCER

TABLE 4

Patient Characteristics and Recurrence Rates in BMCC Study Compared to Rates Among
Untreated Controls from Node-Negative Breast Cancer Studies

Proportion of Patients

Age

Tumor

Recurrence

Years of

Study

<50

>70

< = 2cm

rate

follow-up

BMCC (1979-1983)

.23

.65

.21

5.7

Fisher (1989)3
(NSABP ER — )

.58

.46

.29

Fisher (1989)4
(NSABP ER+)

.31

.58

.23

Monsour (1989)5
(Intergroup)

.62

(. 1 5>60)

(.39< 3)

.31

Goldhirsch (1989)6
(Ludwig)

(.55

premenop)

data

.41

.27

* Data not presented in publication; figures of closest group given for general comparison.

REFERENCES

1 . National Cancer Institute Consensus Conference on the
adjuvant therapy of breast cancer. JAMA 254: 3461,
1985.

2. Clinical alert from the National Cancer Institute, May
16, 1988.

3. Fisher B, Redmond C, Dimitrov NV, et al. A ran-
domized trial evaluating sequential methotrexate and
fluorouracil in the treatment of patients with node-
negative breast cancer who have estrogen-receptor-
negative tumors. N Engl J Med 320: 473-478, 1989.

4. Fisher B, Costantino J, Redmond C, et al. A ran-
domized trial evaluating Tamoxifen in the treatment of
patients with node-negative breast cancer who have
estrogen-receptor-positive tumors. N Engl J Med 320:
479-484, 1989.

5. Mansour EG, Gray R, Shatila AH, et al. Efficacy of
adjuvant chemotherapy in high-risk node-negative
breast cancer; an intergroup study. N Engl J Med 320:
485-490, 1989.

6. Goldhirsch A, Gelber RD and the Ludwig Breast Can-
cer Study Group. Prolonged disease-free survival after
one course of perioperative adjuvant chemotherapy for
node-negative breast cancer. N Engl J Med 320:
491-496, 1989.

7. Nemoto T, Vana J, Bedwani RN, et al. Management
and survival of female breast cancer: results of a na-
tional survey by the American College of Surgeons.
Cancer 45: 2917-2924, 1980.

564

The Journal of the South Carolina Medical Association

NEWSLETTER

DECEMBER 1989

HIGHLIGHTS OF NOVEMBER 16 BOARD OF TRUSTEES MEETING

The Board heard a report on plans for the 1990 Annual Meeting at
the Omni Hotel in Charleston, April 25-29. Topics for plenary
sessions include disaster planning (the Hugo experience) ,
infectious diseases update, wellness, and sports medicine.
Workshops will feature a PRO update, RBRVS, medical ethics,
respiratory management in the elderly, and AIDS/OSHA regulations.
In addition, 10 specialty society groups will hold scientific
sessions. You should receive preliminary information on all
activities, as well as registration forms, in February.

The Board voted to nominate William Goudelock, MD, and John
Simmons, MD, to the board of Medical Review of North Carolina (SC
PRO) . John Simmons, MD, also serves as an at-large member of the
MRNC Executive Committee.

Members of the Board adopted a proposal by the Primary Care,
Medicaid & Indigent Care Committee which would encourage more
physicians to care for Medicaid and indigent patients to assure
that all physicians see their fair share.

The Board commended Scott B. Kleber, MD, a MUSC resident, for his
excellent editorial regarding hurricane Hugo, "A View from the
Hospital," which appeared in the November 17, 1989 issue of JAMA.

MEDICARE UPDATE

Reass icrnment

of Benefits

(Medicare

and Medicaid)

CONTRARY

INFORMATION

PUBLISHED

PREVIOUSLY. THE

HEALTH CARE

FINANCING

ADMINISTRATION

HAS INSTRUCTED CARRIERS THAT PHYSICIANS

MAY NOT BILL

FOR THE SERVICES OF

ANOTHER PHYSICIAN

UNLESS THAT

PHYSICIAN

IN THE EMPLOY OF THE

BILLING PHYSICIAN.

THE HEALTH

AND HUMAN

SERVICES FINANCE COMMISSION MUST ALSO ENFORCE THIS NEW

POLICY FOR MEDICAID.

The following example is cited: If a physician is on call for
another physician and is not employed by that physician, then
both physicians would be required to submit a bill for the
appropriate dates of service to Medicare. Or, if physicians in a
group take call for other members of that group, and the on call

physician is not in the employ of the patient's regular
physician, then each physician would be required to submit a bill
for the appropriate dates of service that the patient was in
their care.

Please look for Medicare's complete article concerning this issue
in your December Advisory from Blue Cross and Blue Shield.

Professional Relations Representatives

Remember, Medicare professional relations representatives are
generally out in the field and not available for routine
telephone inquiries. General questions should be directed to the
appropriate telephone numbers below for timely responses. The
professional relations representatives should handle only matters
that cannot be resolved through the normal Service Center
channels .

Participating: 735-1205, in Columbia

Non-Participating: 735-0624, in Columbia

Termination of Participating Agreement

If you are a participating provider and wish to terminate your
participation agreement, you must do so by December 31, 1989.

You must notify each Medicare carrier that you do business with.
The opportunity to enroll as a participating physician will be
held sometime after January 1, 1990. You will receive more

information from the Medicare carrier concerning this issue as
soon as HCFA makes it available. Refer to Special Bulletin 03-
1189.

New Claims Processing System

Medicare will be implementing a new claims processing system in
early 1990 and is sending monthly Medicare On-Line Bulletins on
how this will affect the providers. The first one was released
in November and references A CHANGE IN MEDICARE PROVIDER ID
NUMBERS. Medicare will issue a bulletin to providers as soon as
plans are finalized as to how the numbers will be changed, so
that maximum time may be given for this change in provider
billing number.

MEDICAID UPDATE

Increased Reimbursement Rates For OB Procedures

In an effort to enable maternal care providers to increase their
participation in the SC Medicaid program, HHSFC has increased the
reimbursement rates for an initial OB Exam (Procedure Code S1500)
to $50 effective for dates of service on or after July 1, 1989.

Maternal care providers will receive enhanced reimbursement if
they are willing to perform some additional services which HHSFC

feels would improve the newborn's chances of survival. The
reimbursement rate for an initial OB exam (Procedure Code SOHO)
would be $100 for referral to the WIC supplemented food program
and referral for any additional services available in the
community and needed by the patient during pregnancy. Such
additional service should be documented, i.e., "referred to WIC
program. "

For follow-up on previous referrals and telephone follow-up for
missed appointments, an antepartum exam (procedure code S0012)
would be reimbursed at $40. An example of appropriate
documentation in this case would be "patient receiving food
supplement from WIC." Patients who repeatedly miss appointments
should be referred to the local health department for maternal
care outreach.

If you have questions, you are encouraged to call Ms. Ricken at
253-6134, in Columbia. Your participation in the SC Medicaid
program is needed and appreciated.

BUDGET RECONCILIATION BILL FOR FY-1990

On November 21, the US House and Senate passed a budget
reconciliation bill for FY-1990 (which actually began on October
1, 1989) . Administration sources indicated President Bush would
sign the bill. Following is a brief description of the major
provisions:

1. RBRVS with a five-year transition beginning in 1992, with a
geographic cost of practice adjustment. There will be no
specialty differential.

2. Rejection of expenditure targets.

3. An advisory Medicare Volume Performance Standard (MVPS) . The
secretary of HHS is required to identify, analyze and report to
Congress the sources of volume increases in Part B, significantly
aiding efforts to debunk the myth that physician gaming is
responsible for volume increases by supplying hard data for the
first time rather than reliance on conjecture and anecdotes.

4. RBRVS Conversion Factor Update: If Congress fails to
establish an update for physician fees, the default update has an
absolute floor — the update could be no less than MEI-2% for
1992 and 1993? MEI-2 1/2% for 1994 and 1995? MEI-3% for 1996.

5. Balance Billing Limits: The House provision prevailed,
setting balance limits as follows:

1990: MAAC's calculated as in 1989.

1991: MAAC's will be capped at a maximum of 125% of
prevailings .

1992: 120% of the nonpar RBRVS payment schedule (maintains
5% differential) .

1993: 115% of the nonpar RBRVS payment schedule (maintains
5% differential) .

6. Physician Submission of Claims: Requires all physicians to
submit claims for Medicare beneficiaries and do so within one
year of date of service (effective 9/1/90) .

7. Practice Guidelines/Outcomes Assessment Research:
Establishes new agency to promote, support, fund and conduct
research into practice guidelines, outcomes assessment and
technology assessment, and to disseminate the results.

8. Self-referral: Starting January, 1992, the bill prohibits
referrals to a clinical lab in which a physician (or immediate
family member) has an ownership interest, and also prohibits
billing by the lab or physician investor for services provided by
such referred to the lab to the physician's patients. There are
exemptions for rural practices, group practices, in-office
services and certain other arrangements. For ALL OTHER SERVICES:
beginning October 1, 1990, entities with physician investors (or
immediate families of physicians as investors) who provide
Medicare services, must provide the secretary of HHS with the
names and provider numbers of those investors.

9. PRO: Physicians are guaranteed the right to a
reconsideration of substandard care denials by a PRO before
notice is given to a beneficiary.

10. The Sequester for Part B services (2.092% reduction in
payments) stays in effect through March 31, 1990.

11. 1990 BUDGET CUTS:

The ME I update for 1990 will be delayed until April 1.
Thereafter, primary care services will receive a full ME-2 update
(5.3%); other services will receive a 2% increase except as noted
below.

For certain overpriced procedures (those identified as being
valued by at least 10% over a comparison of payments for such
service under a RBRVS) , the prevailing charge will be reduced
15%, but no more than 1/3 of the amount to an adjusted prevailing
based on the national weighted average prevailing charge for the
service. As in other overpriced procedures, special MAAC's
apply.

For radiology services, there will be no ME I increase. In fact,
the fee schedule will be reduced by 4%. Special rules apply for
services provided by nuclear physicians (80% of part B services
are nuclear medicine) . A new fee schedule will be established
based 1/3 on the radiology fee schedule and 2/3 based on 101% of
the 1988 prevailing charge for the service.

For anesthesia service, actual time will be used instead of

rounding to the nearest quarter hour.

New physician customary charges will be set at 85% of the
prevailing charge.

Where surgery, radiology and diagnostic physicians' services are
performed by more than one specialty, the prevailing charge for
that service may not exceed the prevailing charge or fee schedule
for that specialty which furnishes the service most frequently
on a nationwide basis.

For clinical laboratory services, the maximum fee schedule will
be 93% of the average of all fee schedules across the country.

Shell laboratories will be prohibited. To avoid being a shell
lab, the lab will have to be located in a rural hospital, be
wholly owned by the referring lab, or refer no more than 3 0% of
the clinical lab tests for which it bills.

PRO UPDATE

Diagnosis and Procedure Changes on Attestation Statement

HCFA recently changed the instructions Carolina Medical Review
(CMR) had received earlier on the requirements for a physician
acknowledging changes in diagnoses and procedures on the
attestation statement. It is now acceptable for the physician to
initial and hand-date such changes, rather than using his/her
full signature, as was originally requested.

Release of Physician-Specific Quality Information to Hospitals

HCFA' s position on the release of physician-specific quality
information to hospitals has been clarified as follows:

1. PROs may disclose physician-specific information related to
one or more confirmed quality problems, with or without a request
by the hospital.

2. The PRO cannot release information on potential problems or
the corrective actions to be taken on confirmed cases. In
addition, any information on a case or group of cases that are
being used to develop a sanction recommendation cannot be
disclosed.

Based on these changes by HCFA, the MRNC/CMR Board of Directors
voted to cancel the previous CMR policy and immediately
incorporate the following policy:

"CMR will release physician-specific information to the
hospital in which the care was provided, on a case-by-case basis,
upon confirmation of a quality problem after the final physician
consultant evaluation. This information will be released without
a specific request from the hospital."

FEDERAL PROFICIENCY TESTING REQUIREMENTS FOR PHYSICIAN OFFICE
LABORATORIES

As reported earlier in this newsletter, the Clinical Laboratory
Improvement Amendments of 1988 mandate that, by July 1, 1991,
every physician office laboratory must meet minimum federal
certification standards. These include quality assurance
control, personnel standards and successful completion of
proficiency testing for each examination and procedure performed
in the laboratory for which proficiency testing is available —
with just a few exceptions. The exceptions are laboratories that
limit their testing to only certain "waivered" tests that either
"employ methodologies that are so simple and accurate as to
render the likelihood of erroneous results negligible, or which
pose no reasonable risk of harm to the patient if performed
incorrectly." Government officials say the necessary regulations
probably will not be available until January 1.

The AAFP, the American Society of Internal Medicine, the College
of American Pathologists and the AMA last year jointly formed the
Commission on Office Laboratory Assessment (COLA) which has as
its specific purpose the accreditation of physician office
laboratories. Four groups currently offer proficiency testing
(PT) programs to which physicians or laboratories may subscribe
to comply with that part of the new law. They are the American
Society of Internal Medicine, the College of American
Pathologists, the American Association of Bioanalysts and the
American Academy of Family Physicians.

PUBLICATIONS AVAILABLE

The AMA Department of Practice Development Resources is offering
a new publication entitled "How to Evaluate a Managed Care
System Contract," which contains questions physicians should ask
in evaluating an offer and the implications of the answers. It
includes a format for figuring the financial impact of a managed
care contract on a practice, a case study illustrating the
contract evaluation process, and step-by-step worksheets for
ongoing management of a practice and for evaluating new and
existing contracts. The OP number is 035 and the price is $4 5
for AMA members and $65 for non-members. To order, call (800)
621-8335.

Orders are being taken for the 1990 edition of Current Procedural
Terminology (CPT) which is available this month. CPT provides
the most widely accepted system of descriptive terms and codes
for reporting physician procedures and services under government
and private insurance programs. Prices for AMA members are
$26.40 for the manual and complimentary Minibook, and $26.40 for
CPT Hospital Outpatient Services. The corresponding prices for
non-members are $3 3 each. CPT 1990 is also available in floppy
disk format and magnetic tape. For more information or to order,
call (800) 621-8335.

TRENDS IN PUBLIC KNOWLEDGE
AND ATTITUDES ABOUT AIDS,
SOUTH CAROLINA, 1987-1988*

JEFFREY L. JONES, M.D., M.P.H.

DANIEL T. LACKLAND, M.S.P.H.

LYNDA D. KETTINGER, M.P.H.

WILLIAM B. GAMBLE, JR., M.D., M.P.H.

Knowledge and attitudes about acquired im-
munodeficiency syndrome (AIDS) and human
immunodeficiency virus (HIV) may help to
influence an individual’s behavior as it relates
to disease transmission. In addition, knowl-
edge and misconceptions about AIDS and HIV
may influence society’s approach to control of
the disease. We report here AIDS knowledge
and attitudes from statewide surveys com-
pleted in 19871 and 1988 and discuss trends in
the results.

BACKGROUND

As of June 30, 1989 there were 656 reported
cases of AIDS and 2,646 reported cases of HIV
infection in South Carolina which has a pro-
jected 1989 population of 3.5 million.2 South
Carolina ranks 24th for the annual incidence
rate of AIDS, 7.3 per 100,000.3 The state popu-
lation is approximately 68 percent white, 31
percent black, and one percent other race.

METHODS

Seventeen questions addressing AIDS and
HIV knowledge and attitudes were appended
to the South Carolina Behavioral Risk Factor
Surveillance System (BRFSS) in 1987 and
1988. The BRFSS was established in South
Carolina in 1983 through a cooperative agree-
ment with the Centers for Disease Control.
The primary purpose of the BRFSS is to pro-
vide data on selected health risk factors by
conducting a monthly telephone survey of a
representative sample of the state’s adult
population.

Approximately 1 50 respondents per month

* From the South Carolina Department of Health and
Environmental Control, 2600 Bull Street, Columbia,
S. C. 29201 (address correspondence to Dr. Jones).

18 years of age or older were selected by a
random 3-stage cluster design and interviewed
by telephone.4 Four trained telephone inter-
viewers conducted evening interviews for one
week during each month. Ten percent of the
interviews were monitored; five percent were
verified by callback. Refusals were called back
on a different day and time. The response rate
was 85 percent in 1987 and 81 percent in 1988
by criteria of the Council of American Survey
Research Organizations.

Questions addressed five major areas: at-
titudes about AIDS, general knowledge about
AIDS, knowledge of HIV transmission by ca-
sual contact, knowledge of HIV transmission
by sex and intravenous drug contact, and
knowledge of HIV transmission by blood
transfusion and donation. The questions were
developed by the South Carolina Department
of Health and Environmental Control AIDS
Program staff, adapted from questions recom-
mended for the National Health Interview Sur-
vey developed by the National Center for
Health Statistics. The data for 1987 and 1988
were weighted by age, race and sex utilizing the
projected 1985 South Carolina population as a
standard.

RESULTS

The 1987 and 1988 results for the five cate-
gories of questions are presented in Table 1.
For each of the 1 7 questions, the percent indi-
cating the correct response is given. Highlights
and trends are discussed in the text.

Most respondents had heard of AIDS (99%)
and considered themselves knowledgeable or
very knowledgeable about AIDS (75% to 80%).
Over 90 percent of those interviewed in both
1987 and 1988 gave correct responses to ques-
tions about sex and IV drug transmission.

December 1989

577

KNOWLEDGE ABOUT AIDS

Table 1. Public knowledge and attitudes about AIDS, DHEC behavioral risk factor survey.
South Carolina 1987 and 1988. Percent giving correct responses.

Questions (paraphrased)

1987 (%)*
N=1793

1988 (%)
N=1854

Attitudes:

1. Do you think AIDS is a health problem in South Carolina? (yes)

2. Should a child with the AIDS virus be kept out of school? (no)

3. Should people infected with the AIDS virus be banned from jobs
where they have brief contact with other people? (no)

General Knowledge:

1. Have you ever heard of AIDS? (yes)

2. How would you rate your personal knowledge of AIDS? (k or vk)**

3. Can a person who looks and feels healthy be infected with
the AIDS virus? (yes)

4. Do you think there is a reliable and accurate test to
detect the AIDS virus? (yes)

Blood Donation and Transfusion:

1. Do you believe a blood transfusion from the Red Cross or
similar blood bank is safe from AIDS? (yes)

2. Can a person become infected with the AIDS virus by
giving blood? (no)

3. Can a person become infected with the AIDS virus by
getting a transfusion from an infected person? (yes)

Casual transmission:

1. Can a person become infected with the AIDS virus by
touching a door knob? (no)

2. Can a person become infected with the AIDS virus by
working with an infected person? (no)

3. Can a person become infected with the AIDS virus by kissing
an infected person on the cheek? (no)

4. Can a person become infected with the AIDS virus by drinking
from the same glass as an infected person? (no)

Sex and IV Drug Transmission:

1. In the United States, do you think the AIDS virus can be

passed on as a result of sex between a man and a woman? (yes)

2. Can a person become infected with the AIDS virus by having
sex with an infected person? (yes)

3. Can a person become infected with the AIDS virus by sharing
an injection needle with an infected person? (yes)

* 95% Cl + 2.3%

** Knowledgeable or very knowledgeable

578

The Journal of the South Carolina Medical Association

KNOWLEDGE ABOUT AIDS

In the areas of casual transmission, testing,
and blood donation respondents were less
knowledgeable (12% to 62% of respondents
gave incorrect answers to questions in these
categories). However, the responses to ques-
tions about casual transmission, testing, and
blood donation showed improvement when
comparing 1988 responses with those from
1987. Responses to attitude questions indi-
cated that fewer people favored keeping HIV
infected persons out of school and work in
1988 than in 1987.

DISCUSSION

It is apparent from the results of these state-
wide surveys that knowledge about AIDS and
HIV transmission is increasing. This increase
has also been identified in national surveys.5
Many factors may be responsible for the in-
crease in knowledge including television, ra-
dio, and newspaper coverage of AIDS; the
Public Health Service brochure mailed to most
households in the United States in 1988;
efforts of national, state and local health de-
partments; school AIDS education; and infor-
mation and education provided by private
medical providers.

Respondents were very knowledgeable
about transmission by the high risk behaviors
addressed in this questionnaire. However,
there were many misconceptions about HIV
testing, casual transmission, and blood dona-
tion. Of particular concern is the belief that
HIV can be transmitted when giving blood (in
1988 only 42 percent of respondents indicated
that it was not possible to transmit AIDS by
giving blood). In a national survey 67 percent
of respondents indicated it was not possible or
unlikely that HIV could be transmitted by do-
nating blood.6

A limitation of the BRFSS is that it does not
include interviews of those without telephones.
This may bias the data against the economi-
cally disadvantaged, a group which may have a
higher risk of acquiring HIV. The 1980 census
found that approximately 10 percent of house-
holds in South Carolina did not have tele-
phones.7

The South Carolina AIDS knowledge and
attitude surveys have been used to design edu-
cational programs statewide. In addition,
knowledge and attitude surveys are being used

in South Carolina to evaluate AIDS and HIV
educational efforts.

SUMMARY

The South Carolina Department of Health
and Environmental Control AIDS Program
assessed the state population’s knowledge and
attitudes about AIDS and HIV transmission in
1987 and 1988. Each year approximately 1,800
adults were selected by a random 3-stage clus-
ter design and asked seventeen questions by
telephone about AIDS and HIV. Questions
addressed attitudes, general knowledge, HIV
transmission by casual contact, HIV transmis-
sion by sex and IV drug contact, and HIV
transmission by blood donation and transfu-
sion. Over 90 percent of respondents were
knowledgeable about HIV transmission by
high risk behaviors addressed in the question-
naire. Respondents were less knowledgeable
about HIV transmission by casual contact (12
to 41 percent gave incorrect answers), HIV
testing (45 to 48 percent gave incorrect an-
swers), and transmission by blood donation
(43 to 52 percent gave incorrect answers). In
general, a higher percentage of correct re-
sponses were given in 1988 than in 1987. In
regard to responses measured by this survey,
we conclude that: (1) there is a high level of
knowledge in the state about transmission by
high risk behaviors, (2) there are still many
misconceptions about casual transmission,
HIV testing, and blood donation, and (3) there
was improvement in knowledge about AIDS
and HIV from 1987 to 1988. □

REFERENCES

1. Monitoring AIDS knowledge and attitudes in South
Carolina, 1987. .Analysis by age, race, sex and educa-
tion. Submitted to Public Health Reports.

2. Wetrogan, SI: Projections of the population of states by
age, sex and race: 1988 to 2010. U. S. Department of
Commerce and Bureau of the Census, October 1988.

3. HIV/AIDS Surveillance. Centers for Disease Control,
U. S. Department of Health and Human Services, July
88-August 89.

4. Gentry EM, et al.: The behavioral risk factor surveys:
design, methods, and estimates from combined state
data. Am J Prev Med 1: 9-14, 1985.

5. National Center for Health Statistics. AIDS knowledge
and attitudes for December 1988. Advance Data 175,
May 31, 1989.

6. National Center for Health Statistics. AIDS knowledge
and attitudes for September 1987. Advance Data 148,
Jan 18, 1988.

7. United States Bureau of the Census, 1980.

December 1989

579

Editorials

PEACE AND GOOD WILL

Among the blessings of the holiday season is
the opportunity to set our priorities for the
coming year, to reflect upon what really mat-
ters in our lives. Looking back on 1989 and
looking forward to 1 990, two observations give
special meaning to this year’s reflections.

Looking back, there was Hugo. The current
volume of The Journal opened last January
with a reminder by our association’s president
that South Carolina is a poor, small, and “very
provincial” state — usually at or near the bot-
tom in various national rankings.1 It seems
cruel and ironic that our state should have
borne the brunt of the most costly natural
disaster in the history of the United States. The
hurricane’s terrible capriciousness gave com-
pelling proof that we are never in full control of
our individual or collective destinies.

Looking forward, this year’s holiday season
marks the beginning of the last decade of the
second millennium — A.D. (Anno Domini) or
C.E. (Common Era), however one chooses to
call it. Two thousand years might seem like a
rather trivial span from the anthropologist’s
perspective that our species is some 4.5 million
years old. Yet judging from the way things
have been going lately, the prospects for an-
other two thousand years do not seem es-
pecially bright for Homo sapiens. Within our
lifetimes, we have already seen the appearance
of two unique and unprecedented threats to
species survival: first nuclear weapons and
now AIDS. We can anticipate that the nineties
will be, among other things, a time for re-
evaluating our collective worldview.

In Hugo’s wake, a substantial portion of
South Carolina now seems makeshift: make-
shift dunes for our beaches; even makeshift
shelters for endangered species such as the red-
cockaded woodpecker. We might recall that
Time began 1989 by naming the earth “planet
of the year” — a fragile planet assaulted on
many fronts by 20th century human activities.2

We, like the red cockade, live within narrow
parameters — parameters paradoxically threat-
ened by progress made possible by science.
Can we, as physicians, offer any special in-
sights into how to make scientific progress
somehow compatible with the long-range in-
terests of humanity and of life on earth?

Perhaps. The most optimistic point of view,
I suggest, is that put forward two years ago in
The Journal by Dr. C. D. Bessinger, Jr., of
Greenville: the concept of “reverence for life”
as applied to our daily clinical practices.3
Within this concept, we have as physicians a
unique opportunity to grapple first-hand with
the tension between what might be called the
scientific and the religious (in the very broad-
est sense) approaches to the human predica-
ment. It may be useful to review briefly the
history of this tension (Figure).

In Western thought, the tension arose on
opposite shores of the Mediterranean in the
ancient world. To explain nature’s apparent
order and purpose ( telos ), the Israelites turned
to Yahweh. Meanwhile, Greeks such as De-
mocritus and Aristotle turned to science. An
uneasy truce forged by the early Christians —
who wrote and thought in Greek — was con-
summated by St. Thomas Aquinas’ brilliant
synthesis whereby all of nature attested to the
glory of God. Aquinas, it has been said, bap-
tised Aristotle. Regrettably, the church failed
to understand that science is a way of thinking,
not a body of facts — a verb rather than a noun.
Hence, the discrediting of dogma was seen as
unacceptable, and Galileo had to go. Sir Isaac
Newton tried valiantly to bring all of knowl-
edge back together, but his argument didn’t
hold. Today, both psysicists and molecular bi-
ologists attribute the smallest, most funda-
mental events to random chance — just as
Democritus in ancient Greece had predicted
would be the case. To an ever-increasing ex-
tent, science and religion have come to be

580

The Journal of the South Carolina Medical Association

ANCIENT

ISRAEL

AND

GREECE

EARLY

CHRISTIANITY

THOMAS AQUINAS
(13th C.)

ISAAC NEWTON
(late 17th C.)

DAVID HUME
IMMANUEL KANT
(18th C.)

REVELATION

OLD

TESTAMENT

THEISM

REASON

THOMISTIC

SYNTHESIS

NATURAL PHILOSOPHY

| NATURAL

NATURAL

THEOLOGY

SCIENCE

RELIGION

SCIENCE

FIGURE. A brief overview of the tension between religion and science in Western thought (see text).

viewed as separate, watertight compartments
of human thought.4

Whatever our perspectives may be on the
Big Question — the question of ultimate telos
or First Cause — we should rejoice as physi-
cians in our daily opportunity to combine the
competing traditions. In no other profession is
it so easy to blend in one’s daily work what
Osier called “philanthropia and philotech-
nia — the joy of working joined in each one to a
true love for his brother.”5 Today, we joyfully
apply such tools as lasers, nuclear magnetic
resonance, and monoclonal immunoglobulins
to our daily medical practice. Simultaneously,
the new science brings ethical problems of un-
precedented scope. Hence, in both areas (phil-
anthropia and philotechnia), the challenges
have never been greater nor more exciting. In
perhaps no other profession is it so readily
feasible to combine the two traditions by using,
as Dr. Bessinger suggests, “reverence for life”
as a unifying principle. In no other profession
is it so feasible to lose oneself in the service of

others and — in so doing — to teach by example,
to instill the value of having values.

“Reverence for life” is not a passive quality,
but rather an extremely active process. Its facil-
itating virtues include courage and humility.
But to be effective, we must have a clear sense
of our own priorities. For ourselves, for each
other, and for our patients, the traditional sa-
lutation of the holiday season seems a good
place to start. Peace on earth, good will toward
men.

— CSB

REFERENCES

1. Rowland TC Jr: Lowest is best. JSC Med Assoc 85: 3,
1989.

2. Planet of the year: what on earth are we doing? Time,
January 2, 1989.

3. Bessinger CD Jr: Reverence for life in clinical practice. J
SC Med Assoc 83: 69-71, 1987.

4. Pro vine W: Scientists, face it! Science and religion are
incompatible. The Scientist, September 5, 1988.

5. Osier W: The old humanities and the new science. Brit
Med J 2: 8-33, 1919.

December 1989

581

During October’s Red Ribbon Week, we were reminded that alcohol and other drugs are involved
in 50% of all fatal automobile accidents; 80% of all fire deaths; 69% of all drownings; 55% of all
arrests; 35% of all rapes; 30% of all suicides; 60% of all child abuse cases; and 85% of all homicides.
Next month ’s issue o/The Journal will be devoted entirely to the problem of chronic alcoholism and
other substance abuse. In this issue, Dr. Stephen Holt provides an overview of the clinician ’s role, and
in the following editorial he also makes a case for secondary prevention (as opposed to primary or
tertiary intervention). Guest editorials represent the opinions of the authors and do not necessarily
reflect the policies or positions of the South Carolina Medical Association.

— CSB

TACKLING THE ALCOHOL PROBLEM:

THE CASE FOR SECONDARY PREVENTION

Alcohol abuse and its consequences present
pervasive problems that have major medical,
political and socio-economic implications.1’ 2
The problems that arise from the way alcohol
is used in our society result from ambivalent
attitudes. Drinking is perceived as appropriate
for various social events and “sociability” may
be reinforced by excessive drinking. Our con-
sumer society is bombarded with advertise-
ments that associate drinking with sporting
pursuit, elegance and even healthy lifestyle.3
Excessive drinkers, whether sociable, mis-
guided, sinful or diseased, are often rejected,
especially when the pleasant drunk becomes
antisocial or ill. Approval and condemnation
of alcohol go hand in hand.

The United States Department of Health
and Human Services has highlighted alcohol
and drug abuse as a target objective for the
nation in 1990.4 Recently, the U. S. Congress
commissioned the Institute of Medicine in
Washington to make recommendations for
new legislation to tackle alcohol problems. Al-
cohol abuse is the most serious human service
problem in South Carolina and, on the whole,
the abuse of alcohol and other drugs costs the
state economy $2.8 billion dollars each year.5
This cost approximates to the same amount as
the entire annual budget of the government of
South Carolina. In our state, admissions to
treatment programs for alcohol abuse appear
to be rising and total pure alcohol consump-
tion per capita in the population over the age of
18 years may exceed the national average in
1989. 5 The encouraging findings that the per-
centage of the adult population of South Caro-
lina who drink or are heavy drinkers appear
lower than national averages should be viewed

with caution. Justification for such caution
emanates from the finding that five percent of
the adults in South Carolina drink at least one
half of all the alcohol consumed,5 revealing the
existence of a distinct and large group of prob-
lem drinkers.

The early identification of alcohol abuse and
intervention, at a stage when the prognosis for
recovery is good, would appear to be an attrac-
tice option to reduce the prevalence of alcohol
related morbidity.1'3 Some of the potential ad-
vantages and disadvantages of levels of pre-
vention that can be applied to alcohol abuse
are summarized in Table 1. Primary preven-
tion does not appear feasible by virtue of its
connotations or political implications, where-
as tertiary prevention, that involves rehabilita-
tion of patients with adverse sequelae of
excessive drinking, will not reduce the preva-
lence of alcohol abuse.1'3 The focus of medical
management is traditionally at the tertiary
level where cure is not possible, morbidity is
inevitable and mortality may be predeter-
mined. For example, it has been estimated that
between 30 and 50 percent of heavy drinkers
may with time develop alcoholic liver disease
and an erroneous perception has prevailed that
“alcoholics” with liver disease account for the
majority of alcohol related morbidity, mor-
tality and financial liability.1 Frequently, phy-
sicians and allied health care workers may
focus their attention on the biomedical conse-
quences of excessive alcohol intake at the ex-
pense of considering the significant social and
economic burden that the early problem
drinker may pose to society.6

The concept of secondary prevention for al-
cohol problems is as “old as the hills” but as

582

The Journal of the South Carolina Medical Association

Level of Prevention

Advantages

Disadvantages

Primary Potentially effective Lack of political and social

ACCEPTANCE

Will reduce prevalence of

ALCOHOL PROBLEMS HISTORICALLY UNSUCCESSFUL

IN LONG TERM

Secondary Effective in early studies Requires change in medical

AND "SOCIAL" PRACTICE

Readily applied using

VALIDATED DETECTION COST?

INSTRUMENTS

"Alcoholism" is not a "clear
cut" syndrome

Tertiary

Traditional medical focus
Deals with consequences of

LONG TERM PROBLEM DRINKING

"Too LATE" FOR RECOVERY

Will not reduce prevalence

OF ALCOHOL PROBLEMS

Not cost-effective?

Table 1: Some advantages and disadvantages of

to tackle alcohol problems.

topical as ever.1'3’7 Despite promising evi-
dence that secondary prevention may be bene-
ficial,1 identification of alcohol problems and
intervention in clinical practice have not
gained widespread acceptance.7 In the same
way that alcohol abuse may arise from an am-
bivalent attitude in our society, such am-
bivalence in medical or “social” practice
contributes to our inability to impact alcohol
problems.

With few exceptions, screening for alcohol
problems in the U.S.A. appears to be applica-
ble only in health care settings.2 Screening
should proceed ideally in high risk groups and
the level of sophistication of an assessment
measure of alcohol problems should be tai-
lored to the clinical context.1’ 2 Secondary pre-
vention for alcohol problems remains embry-
onic in its application and may have most
chance of success in selected areas such as
general medical clinics, community health
programs, and hospital emergency depart-
ments.1’ 2’ 6-8

General population screening by non-physi-
cian, health care personnel is an attractive pos-

levels of preventive efforts that can be used

sibility that may have daunting financial
implications, especially if case finding results
in a swamping of treatment facilities.2 A clinic
nurse or nurse practitioner who has a clear role
in patient contact may be an ideal individual to
engage in identification and limited interven-
tion. However, the plot is not so simple.1 It
seems likely that a significant proportion of
patients attending a medical clinic for a spe-
cific complaint may react adversely to the ap-
parent intrusiveness of screening for alcohol
problems. Invasion of privacy, potential vio-
lation of rights and fear of “labeling” com-
pound the issues. Furthermore, would all
patients elect to pay directly or indirectly for a
service they may not want, even if they need
it?1 In addition, to extol the virtues of second-
ary prevention for alcohol problems may at
first sight seem unattractive to the busy physi-
cian who does not have time or cannot “afford”
to conduct interviews or clinical examinations
aimed at the detection of problem drinking.
Such excuses for medical procrastination may
be mitigated by the recent development of
brief diagnostic instruments7'9 that can be im-

December 1989

583

plemented readily in clinical practice to detect
problem drinkers.

Political legislation that would materially
influence the widespread institution of early
intervention for alcohol problems could focus
on the financing of health care.10 There is no
doubt that designation of federal or state funds
for secondary prevention of alcohol problems
could lead to establishment of widespread
screening and intervention which could in turn
lead to a reduction in the prevalence of alcohol
abuse and problems. Political pressure applied
to insurance carriers and hospital management
organizations to support secondary prevention
is consistent with the current “wellness con-
cepts” that have percolated medical practice
and the professed intention of these organiza-
tions. Appropriate political legislation that
would facilitate widespread secondary preven-
tion of alcohol abuse will be a major long-term
investment in the health of American citizens.
If this prevention reduces the prevalence of
alcohol problems, then there would be enor-
mous social and economic advantages for the
nation.4 Proponents of the economic reform of
health care services, that is aimed at cost con-
tainment, must be more cognizant of the po-
tential long-term benefits of preventive medi-
cine, especially where alcohol and other sub-
stance abuse are concerned.

Pandora’s box is open, “hope” remains but
procrastination persists. To date, no medical
or political action has succeeded in reducing
the prevalence of excessive alcohol consump-
tion in a consistent manner.3 Medical atten-
tion has focused on the advanced problem
drinker where significant social and medical
disability frequently negates recovery.2 In con-
trast, political inertia has resulted in a lack of
sufficient encouragement or financial support
for preventive measures.3 Politicians have
been unwilling to implement primary preven-
tive measures and it seems to be clear that the
application of secondary prevention for alco-
hol abuse may achieve more than any foreseea-

ble political action.10 A joint medical and
political effort that endorses case finding and
intervention provides a logical approach for
improving the short and long term well being
of problem drinkers who comprise a signifi-
cant proportion of the population of North
America.

Stephen Holt, M.B.

Department of Medicine
University of South Carolina
School of Medicine
2 Richland Medical Park,

Suite 506

Columbia, S. C. 29203
REFERENCES

1 . Skinner HA, Holt S, Israel Y. Early Identification of
Alcohol Abuse: Critical Issues and Psychosocial Indi-
cators for a Composite Index. Canadian Medical Asso-
ciation Journal 124:1141-1152, 1981.

2. Holt S, Skinner HA, Israel Y. Early Identification of
Alcohol Abuse: Clinical and Laboratory Indicators.
Canadian Medical Association Journal 1 24: 1279-1 294,

1981.

3. Holt S, Skinner HA, Israel Y. Confronting alcoholism.
Canadian Medical Association Journal 126:351-352,

1982.

4. U. S. Department of Health and Human Services.
Promoting Health/Preventing Disease: Objectives for
the Nation. Washington, D. C.: Government Printing
Office , 1980.

5. Nalty DF, (personal communication) data on file at
South Carolina Commission on Alcohol and Drug
Abuse, 1989.

6. Skinner HA, Holt S. Early Intervention for Alcohol
Problems. Journal of the Royal College of General
Practitioners 33:787-79 1 , 1983.

7. Babor TF, Weill J, Treffardier M, Benard JY. Detec-
tion and diagnosis of alcohol dependence using the Le
Go grid method. In: Chang, N. C. and Chao, H. M.
(Eds.) Early Identification of Alcohol Abuse. Research
Monograph No. 17. Rockville, MD: National Institute
on Alcohol Abuse and Alcoholism. DHHS Pub. No.
(ADCM) 85-1258, 1985.

8. Skinner HA, Holt S, Schuller R, Roy J, Israel J. Identi-
fication of Alcohol Abuse Using Laboratory Tests and
a History of Trauma. Annals of Internal Medicine
101:847-851, 1984.

9. Skinner HA, Holt S, Sheu WJ, Israel Y. Clinical Versus
Laboratory Detection of Alcohol Abuse: the Alcohol
Clinical Index. British Medical Journal 292:1703-1708,
1986.

10. Kendall RE, Alcoholism: Medical or a Political Prob-
lem. British Medical Journal 1:367-371, 1979.

584

The Journal of the South Carolina Medical Association

On tl;e Cover

THE MEDICAL SOCIETY OF SOUTH CAROLINA

On Christmas Eve 1 989, the Medical Society
of South Carolina will celebrate its 200th birth-
day. Formed by a group of Charleston “Gen-
tlemen, Practitioners of Medicine” to “pro-
mote liberality in the Profession, and Har-
mony amongst the Practitioners in this City,”
the Society has, through the years, performed
its mission well. Three of its more outstanding
and lasting contributions to medicine in South
Carolina are represented on this month’s
cover.

On January 1 , 1 824, in response to a petition
by the Medical Society, an Act of Incorpora-
tion of a medical school passed the South Caro-
lina Legislature. This act allowed the Society to
organize a medical school, to institute pro-
fessorships, and to confer medical degrees.
One serious flaw in the act which would not be
corrected until the 20th century was the lack of
state funding for the new school. The problem
of raising monies fell to the newly elected fac-
ulty. Nevertheless, through schism, earth-
quake, epidemics and war, the medical college
continued, at times eliminating tuition fees
entirely, often assessing from the faculty
money to carry on. The doors were closed only
once: from 1861 to 1865. Though no longer
under the governance of the Medical Society,
the medical college, now the Medical Univer-
sity of South Carolina, is a proud reminder of
the foresight of the Society.

With a bequest from Charleston philanthro-
pist Thomas Roper as a start, the Medical
Society erected the first Roper Hospital on the

corner of Queen and Mazyck Street in 1852.
This hospital, the first community hospital of
any size in the state, was opened for regular use
in 1856. Its purpose, according to the will of
Mr. Roper, was “for the permanent reception
or occasional relief of all such sick, maimed
and diseased paupers as need surgical or medi-
cal aid and whom without regard to complex-
ion, religion or nation I would they should
admit therein.” Roper Hospital, now on its
third site, is still growing, still serving the com-
munity, and still governed by the Medical
Society.

The third major accomplishment of the
Medical Society of South Carolina was the
formation of the South Carolina Medical Asso-
ciation. After Charleston doctors were instru-
mental in the formation of the AMA in 1 847,
the Society felt the need of a state organization,
and in 1848, called a convention for the pur-
pose of establishing such a group. On February
14, the convention convened and proceeded to
resolve itself into the South Carolina Medical
Association. The Medical Society became one
of the constituent district societies which made
up the state association.

We applaud the Medical Society for its
proud heritage and its years of service to the
people of South Carolina and wish for them
that the next 200 years be as productive.

Betty Newsom

The Waring Historical Library

December 1989

587

PHYSICIAN RECOGNITION AWARDS

The following SCMA physicians are recent recipients of the AMA’s Physician Recognition
Award. This award is official documentation of Continuing Medical Education hours earned.

John L. Abt, D.O.

James R. Allison, M.D.
Frank A. Axson, M.D.

Larry D. Bartel, M.D.
William R. Bixenman, M.D.
Walter B. Blum, M.D.

Edwin Cruz, M.D.

Jean M. De La Mothe, M.D.
Marvin Dees, M.D.

Nguyen N. Giep, M.D.
Jennifer C. Hedgepeth, M.D.
Douglas E. Holford, M.D.
Malvern C. Holland, M.D.
Ernest F. Krug, M.D.

Ralph E. Lattimore, M.D.

Sara M. Lindsay, M.D.

Richard P. Milligan, M.D.
Jeffrey A. Siegel, M.D.

Eugene F. Smith, M.D.

Ronald M. Tollison, M.D.
Richard E. Townsend, M.D.
Kenneth R. Warrick, M.D.

Carl E. Weimer, M.D.

Patricia P. Westmoreland, M.D
Lloyd B. Williams, M.D.
Woodrow B. Williams, M.D.
Robert A. Ziff, M.D.

The New Duke Geriatric
Education Center

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Health Promotion
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Write:

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Box 3003

Duke University Medical Center
Durham, NC 27710
or call: (919) 684-5149

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Columbia, S. C. 29202

588

The Journal of the South Carolina Medical Association

WHAT IS AMA/ERF?

American Medical Association Education and Research Foundation (AMA/ERF) — what does it
mean to you? Why do I witness so much enthusiasm year after year for AMA/ERF? What do they
know that I don’t?

The AMA/ERF was established by the AM A Board of Trustees over 35 years ago to help support
quality education in the nation’s medical schools. Since that time, the foundation has distributed
more than 48 million in gifts to medical schools and guaranteed over 95 million in loans, benefiting
more than 40,000 medical students, interns and residents.

The individual contributor designates to which medical school his or her tax deductible donation
is given. The contributor also chooses between the Medical School Excellence Fund and the
Medical Student Assistance Fund.

The Medical School Excellence Fund is the oldest of the funds and the largest. Grants are
provided to the medical schools to use as they see fit. Often these monies are the only unrestricted
funds that the dean may use. These deans repeatedly stress their appreciation for the flexibility this
allows in supporting varied activities. They have been remarkable in accounting for the funds
received. The following quotes are from deans of medical schools.

‘'Areas which benefit from the excellence check are the student’s opportunity to hear guest
lecturers, the attendance and participation in continuing education courses, presentation of
papers at national meetings and the purchase of equipment and subscriptions to professional and
scientific publications. We have used these funds for the summer student research fellowship
program, freshman orientation, minority physician seminar, career decision-making workshop
and cost of the yearly graduation reception. Giving unrestricted funds allows the dean to initiate
new programs, rescue programs of worth and provide the necessary tools and atmosphere for a
quality education. ”

The Medical Student Assistance Fund requires that the schools use the funds to help support
bonafide educational expenses for medical students. Again, the deans are quoted:

“The monies restricted for student assistance will be used to assist students with temporary,
interest-free loans to pull them through critical budgeting problems. ” “This gift will be added to
our existing student loan fund. ” “We are applying the entire amount to our financial aid-loan
program for medical students. This important program is the mainstay of our institutionally-
based financial aid effort and we are deeply grateful. ”

Some schools receive more funds than others. Why? The contributor designates the school to
which the money is given. When local societies and auxiliaries enthusiastically support AMA/ERF,
we see significant increases in the donations to schools from that area. We also see the development
of working relationships between the medical community and the medical school.

To promote the quality of medical education for those young people who will be joining us in
practice for the future health of our communities and our families, whether my child chooses to be
the physician and/or inevitably becomes the patient, I will have participated in affecting the quality
of care given.

Ralph Waldo Emerson: “It is one of the most beautiful compensations of life that no man can
sincerely try to help another without helping himself.”

Linda Galphin (Mrs. Robert L.)

1989-90 South Carolina AMA/ERF Chairman

December 1989

589

INDEX TO VOLUME 85, 1989

AUTHORS

Ashton, Ronald L., M.D 97

Adkins, Warren Y., M.D 441

Atkinson, Larry S., M.D 97, 292

Babcock, William H., M.D 560

Bailey, M.K., M.D 327

Baker, J. D., Ill, M.D 317

Barone, Bartolo, M.D 7

Bauknight, R. Stewart, M.D 444

Best, Ronald G., Ph.D 463

Bowles, James T., M.D 447

Bradham, Gilbert B., M.D 221

Bradham, R. Randolph, M.D 226, 283

Branch, J. David, M.S. 119

Brown, Juan A., M.D 417

Brown, Kenneth A., M.D 425

Bryant, Jane 25

Bowles, James T., M.D 447

Butler, Harvey E., Jr., M.D 503

Caldwell, Samuel T., M.A 62, 311

Carlson, L.S., M.D 409

Carter, Richard M., M.D 403

Clair, Walter K, M.D 103

Cleghorn, G. Dean, Ed.D 239

Colvin, Euta M., M.D 5, 16

Cooke, J. E., M.D 327

Conroy, J. M., M.D 327

Crawford, Fred A., M.D 275

Creasman, William T., M.D 459

Crotwell, Henry F., M.D 97

Cunningham, Calhoun D., M.D 429

Cushing, William J., M.D 503

Davis, Paul T., M.D 429

Deci, Paul A., M.D 509

Denton, William T., M.D 75

Dunbar, C.P., M.D 97

Eleazer, G. Paul, M.D 103

Fairey, William F., M.D 6, 43

Far is, Henry M„ M.D 97

Fravel, William J., M.D 441

Freeze-McElwee, Yvonne, M.S.P.H 481

Fyfe, Derek A., M.D 275

Gaines, James H., D.M.D 33

Gamble, William B., Jr., M.D., M.P.H 577

Garrison, Carol Z., Ph.D 481

Giese, Warren K„ Ph.D 119

Gillette, Paul C., M.D 275

Goforth, Augustus J., Ill, M.D 405

Gould, Warren L., M.D 549

Grimball, Arthur, M.D 226, 283

Hagerty, Richard C., M.D '. 549

Hagerty, Robert F., M.D 549

Hahneman, Betty M., M.D., M.P.H. 560

Halstead, Lucinda A., M.D 447

Hawk, John C„ Jr., M.D 19, 323

Hazlett, Linda Jean, B.A 103

Heins, Henry C., M.D 357

Hendrix, Grady H., M.D 234

Hiott, J. Capers, M.D 403

Hoang, Gien, M.D 415

Holt, Stephen, M.B 554

Holtz, Gary, M.D 59

Hornung, Carlton A., Ph.D 267

Horton, Paul M., Ph.D 62

Hulsey, Thomas C., MSPH, Sc.D 357

Hunt, John R., M.D 36

Hurst, L. Ronald, M.D 417

Hwu-Yun, R., M.D 317

Jackson, Kirby L., B.A 481

Jones, Jeffrey L., M.D 577

Jordan, C. Bryan, II, M.D 292

Jordan, Robert C., M.D 405

Juk, Stanley S., Jr., M.D 119

Keith, James A., Ph.D 119

Kettinger, Lynda D., M.P.H 577

Kilgore, Donald G., Jr., M.D 10

Knutson, Cam, M.S 463

Koob, Cheryl 25

Lackland, Daniel T., M.S.P.H 80, 577

Lawton, Boyce M., Jr., M.D 11

Lee, William M., M.D 75

LeProtti, Stanley J., M.Ed 119

Llewelyn, Timothy, M.D 522

Locklair, P. Reid, M.D 226, 283

Lomax, William R., M.D 425

Mader, Timothy J., M.D 317

Mahon, Robert G., Jr., M.D 415

Majeski, James A., M.D., Ph.D 469

Marshall, Terry A., M.D 357

Martin, Mary Lou, MSN, R.N. 357

McCutcheon, Ernest P., M.D 267

McGee, Tom W., M.A.T. 357

McHugh, Terrance, P., M.D 317

McGowan, Julie Johnson 239

McKeehan, Nancy C., M.S.L.S. 527

Meglen, Marie C., MS, C.N.M. 357

Morgan, William R., M.D 469

Molnar, Sandor, Ph.D 119

Morales, B. Ann, B.A 103

Morse, Harold G., M.D 292

Osguthorpe, J.D., M.D 409

Parrott, Larry H., M.D 113

Patton, Grant W., Jr., M.D 59

Peden, Susie F., BSN, M.H.S.A 357

Pittard, William B., M.D 357

Poland, Robert M., M.A 444

Pollitzer, Richard S., M.D 522

Reynolds, Wade D., M.P.H 331

Richardson, Donald V., Esq 39

Robinson, Clarence G., M.D 119

Royal, Howard G., Jr., M.D 97

Rullan, John V., M.D., M.P.H 80

Salters, Susan, B.A., C.T.R 560

Santos, Alberto, Jr., M.D 509

Schuman, Stanley H., M.D., Dr. P.H. 62, 31 1

Sercy, Judith M., B.S. 103

Smith, Nancy, M.L.S 529

Spurgeon, John H., Ph.D 119

Staff of the Carolina Cleft Lip and Palate Center . . . 549

Stuart, R., M.D 409

Sy, Francisco S., M.D., Dr. P.H 331, 481

Taylor, Ashby B., M.D 275

Taylor, Jeter P., M.D 317

Thompson, Shirley J., Ph.D 560

Tolhurst, John T., M.D 234

Trask, Joseph L., M.D 503

Trask, Neil W., Ill, M.D 503

Tyson, Duncan W., M.D 97

Usher, Bruce W., M.D 503

Wade, Ronald V., M.D 463

Waters, Robert C., M.D 444

Watkins, Stephen L., M.D 522

Wells, David H., M.D 357

Weston, C. Tucker, M.D 10

Wheeler, Frances C., Ph.D 80

White, Charles H„ Jr., M.D 97

Whitlock, Norris H., M.S. 62

Wiles, Henry B., M.D 275

Woodbury, Lee V., M.D 103

Young, S. R., Ph.D 463

ORIGINAL SCIENTIFIC ARTICLES

Acute Pancreatitis in a Five- Year-Old Male —
Timothy J. Mader, M.D., Jeter P. Taylor, M.D.,

Terrance P. McHugh, M.D 317

Advances in the Treatment of Supraventricular
Tachycardia — Paul C. Gillette, M.D., Fred A.

Crawford, M.D., Derek A. Fyfe, M.D., Ashby B.

Taylor, M.D., Henry B. Wiles, M.D 275

Chronic Hepatitis and Indolent Cirrhosis Due to
Methyldopa: the Bottom of the Iceberg? —

William M. Lee, M.D., William T. Denton, M.D. . 75
Clinical Experience with Ciprofloxacin: Analysis of a
Multi-Practice Study — C. P. Dunbar, M.D., Ronald
L. Ashton, M.D., Larry Atkinson, M.D., Henry F.
Crotwell, M.D., Henry M. Faris, M.D., Howard G.
Royal, Jr., M.D., Duncan W. Tyson, M.D., Charles

H. White, Jr., M.D 97

Descending Thoracic Aorta to Femoral Artery
Bypass — R. Randolph Bradham, M.D., P. Reid

Locklair, Jr., M.D., Arthur Grimball, M.D 283

Dynamic Auscultation — Richard S. Pollitzer, M.D.,
Stephen L. Watkins, M.D., Timothy S. Llewelyn,

M.D 522

Gamete Intrafallopian Transfer (GIFT): The South
Carolina Experience — Gary Holtz, M.D., Grant W.

Patton, Jr., M.D 59

How Good (or Bad) is the Pap Smear? — William T.

Creasman, M.D 459

Identification and Intervention for Alcohol Abuse —

Stephen Holt, M.B 554

Idiopathic Arteriovenous Renal Vascular
Malformation Treatment by Ex Vivo Repair —
William R. Morgan, M.D., James A. Majeski,

M.D., Ph.D 469

Intravenous Streptokinase Therapy for Acute
Myocardial Infarction in a Community Hospital:
Effect on Ventricular Function and Mortality —

Joseph L. Trask, M.D., Neil W. Trask, III, M.D.,
William J. Cushing, M.D., Harvey E. Butler, Jr.,

M.D., Bruce W. Usher, M.D 503

Lyme and Other Tick-Borne Diseases Acquired in
South Carolina in 1988: A Survey of 1,331
Physicians — Stanley H. Schuman, M.D., Dr. P.H.,

Samuel T. Caldwell, M.D 311

Lymphomatiod Papulosis: Mostly Benign but
Potentially Malignant — A Case Report with a

Fatal Outcome — Larry H. Parrott, M.D 113

Marfan Syndrome in the Parturient — M. K. Bailey,

M.D., R. Hwu-Yun, M.D., J. D. Baker, III, M.D.,

J. E. Cooke, M.D., J. M. Conroy, M.D 327

Myasthenia Gravis Presenting as Respiratory
Failure: Confusion with a Psychiatric Illness — C.
Bryan Jordan, II, M.D., Harold G. Morse, M.D.,

Larry S. Atkinson, M.D 292

(The) Non-Operative Care of the Vascular Surgical

Patient — Gilbert B. Bradham, M.D 221

Project Readiness II: Some Results from a Physical
Fitness and Health Enhancement Program for Law
Enforcement Personnel — Stanley J. LeProtti,

M.Ed., Warren K. Giese, Ph.D., John H. Spurgeon,
Ph.D., James A. Keith, Ph.D., Stanley S. Juk, Jr.,

M.D., Clarence G. Robinson, M.D., Sandor

Molnar, Ph.D., J. David Branch, M.S. 119

Recurrence of Node-Negative Breast Cancer in
Patients Treated in a Community Hospital — Betty

M. Hahneman, M.D., M.P.H., Shirley J.

Thompson, Ph.D., William H. Babcock, M.D.,

Susan Salters, B.A., C.T.R 560

Schizophrenia: Promising New Directions in South
Carolina — Alberto B. Santos, Jr., M.D., Paul A.

Deci, M.D 509

Seroprevalence of Human Immunodeficiency Virus
in Mental Health Patients — Walter K. Clair, M.D.,

G. Paul Eleazer, M.D., Linda Jean Hazlett, B.A.,

B. Ann Morales, B.A., Judith M. Sercy, B.S., Lee

V. Woodbury, M.D 103

(The) Surgical-Prosthetic Method of Cleft Lip and
Palate Care: Development of a Comprehensive
Program— Robert F. Hagerty, M.D., Richard C.
Hagerty, M.D., Warren L. Gould, M.D., and the
Staff of the Carolina Cleft Lip and Palate Center . 549
Takayasu’s Arteritis — John T. Tolhurst, M.D., Grady

H. Hendrix, M.D 234

Trends in Cardiovascular Mortality and Risk Factor
Levels in South Carolina: Significance for
Prevention — Carlton A. Hornung, Ph.D., Ernest P.

McCutcheon, M.D 267

Trends in Public Knowledge and Attitudes About
AIDS, South Carolina, 1987-1988 — Jeffrey L.

Jones, M.D., M.P.H., Daniel T. Lackland,

M.S.P.H., Lynda D. Kettinger, M.P.H., William B.

Gamble, Jr., M.D., M.P.H. 577

Update on Hospitalized Pesticide Poisonings in
South Carolina, 1983-1987 — Stanley H. Schuman,
M.D., Dr. P.H., Norris H. Whitlock, M.S., Samuel

T. Caldwell, M.A., Paul M. Horton, Ph.D 75

Utilization of Amniocentesis and Chorionic Villus
Sampling by South Carolina Women 35 Years of

Age and Older — Cam Knutson, M.S., S. R. Young,

Ph.D., Ronald V. Wade, M.D., Robert G. Best,

Ph.D 463

Utility of Lesser Saphenous Vein as a Substitute
Conduit — Arthur Grimball, M.D., R. Randolph
Bradham, M.D., F. Reid Locklair, M.D 226

SPECIAL ARTICLES

Access to Online Information: The Hardware

Connection — Nancy Smith, M.L.S. 529

(The) Annual Meeting of the AMA: Report of the

SCMA Delegation — John C. Hawk, Jr., M.D 323

Eradication of Filariasis in South Carolina: A
Historical Perspective — Wade D. Reynolds,

M.P.H. , Francisco S. Sy, M.D., Ph.D 331

Health Promotion Beliefs and Attitudes of
Physicians: A Survey of Two Communities in
South Carolina — Frances C. Wheeler, Ph.D.,

Daniel T. Lackland, M.S.P.H., John V. Rullan,

M.D., M.P.H 80

Knowledge, Perceived Risk, and Beliefs about AIDS
Among High School and College Students in
South Carolina — Francisco S. Sy, M.D., Dr. P.H.,
Yvonne Freeze-McElwee, M.S.P.H., Carol Z.

Garrison, Ph.D., Kirby L. Jackson, B.A 481

Online Information Management: Who Needs It? —

Nancy C. McKeehan, M.S.L.S. 527

Physician Manpower and Graduate Medical
Education: A Review with Implications for State
Policy Development — Julie Johnson McGowan, G.

Dean Cleghorn, Ed.D 239

(A) Report of the AMA Interim Meeting — John C.
Hawk, Jr., M.D 19

SPECIAL ISSUES:

PROFESSIONAL LIABILITY IN
SOUTH CAROLINA

(The) Deposition — The Doctor, The Lawyer —

William F. Fairey, M.D., L.L.B 43

Glancing Back — William F. Fairey, M.D 6

Introduction — Euta M. Colvin, M.D 5

JUA Claims Functions — Boyce M. Lawton, Jr.,

M.D U

Malpractice Prophylaxis — John R. Hunt, M.D 36

Quality Assurance, Quality Management, Risk
Management and Other Buzz Words of the
Eighties — How Do We Use Them? — R. L.

Skinner, Jr., M.D 46

Risk Management — Euta M. Colvin, M.D 47

So You are the Defendant in a Malpractice Action —

Donald V. Richardson, Esq 39

South Carolina Medical Malpractice Joint
Underwriting Association — Bartolo M. Barone,

M.D 7

South Carolina Medical Malpractice Patients’
Compensation Fund — Donald G. Kilgore, M.D.,

C. Tucker Weston, M.D 10

(The) South Carolina Dental Association and the
S. C. Medical Malpractice JUA — James H.

Gaines, D. M.D 33

(The) SCHA Loss Control Program: Reduction in
Liability Exposures for Hospitals and Physicians —

Cheryl Koob, Jane Bryant 25

(The) South Carolina Medical Association/Joint
Underwriting Association Risk Management
Program — Euta M. Colvin, M.D 16

REGIONALIZED PERINATAL CARE
IN SOUTH CAROLINA

Thomas C. Hulsey, MSPH, SC.D., Henry C. Heins,
M.D., Terry A. Marshall, M.D., Mary Lou Martin,
MSN, R.N., Tom W. McGee, M.A.T., Marie C.
Meglen, MS, C.N.M., Susie F. Peden, BSN, M.H.S.A.,
William B. Pittard, M.D., David H. Wells, M.D. . 357

Otolaryngology — Head and Neck Surgery — F.

Johnson Putney, M.D 450

Peace and Good Will — Charles S. Bryan, M.D 580

Peer Review Where It Counts — Charles S. Bryan,

M.D 209

Policy Development for Medical Education in South

Carolina — G. William Bates, M.D 247

Quality Assurance, Quality Management, Risk
Management and Other Buzz Words of the
Eighties — How Do We Use Them? — R. L.

Skinner, Jr., M.D 46

Regionalized Perinatal Care: The Next Step —

C. Warren Derrick, Jr., M.D 495

Risk Management — Euta M. Colvin, M.D 47

SCHIN and GRATEFUL MED (or Computers to

the Rescue!) — Charles S. Bryan, M.D 534

Slow Poisons? — Charles S. Bryan, M.D 86

Tackling the Alcohol Problem: The Case for

Secondary Prevention — Stephen Holt, M.B 582

Tick Distribution in South Carolina — Arthur F.

DiSalvo, M.D 494

Ticks, Terrorism and Tetracylines — Charles S.

Bryan, M.D 341

True (Palmetto) Blue — Charles S. Bryan, M.D 296

Working Together Makes Sense and Progress —

J. O’Neal Humphries, M.D 248

Historical Development 358

Systems Development 363

The Association of Hospital Level of Care with
Mortality Among Infants of Very Low Birth

Weight 375

(A) Review of the Issues 379

Symposium: otolaryngology and

HEAD AND NECK SURGERY

J. David Osguthorpe, M.D., F. Johnson Putney, M.D.

Adjunctive Procedures in Surgery of the Aging
Face — Paul T. Davis, M.D., Calhoun D.

Cunningham, M.D 429

Current Techniques in Evaluation of a Neck Mass —

Robert C. Jordan, M.D., R. Stuart, M.D 405

Dizziness: Current Evaluation — Warren Y. Adkins,

M.D., William J. Fravel, M.D 441

Endoscopic Technique for Sinus Surgery — Juan A.

Brown, M.D., L. Ronald Hurst, M.D 417

External Rhinoplasty — William R. Lomax, M.D.,

Kenneth A. Brown, M.D 425

Hearing Conservation and New Techniques in
Rehabilitation — R. Stewart Bauknight, M.D.,

Robert C. Waters, M.D., Robert M. Poland, M.D. . 444

Indications for Tonsillectomy and Adenoidectomy —
Richard M. Carter, M.D., J. Capers Hiott, M.D. . . 403
Inhalant Allergies: Skin Versus in Vitro Testing —

Gien Hoang, M.D., Robert G. Mahon, Jr., M.D. . . 415
Management of Post-Intubation and Post-Traumatic

Airway Stenosis — Lucinda A. Halstead, M.D.,

James T. Bowles, M.D 447

Multimodality Treatment of Advanced Head and
Neck Carcinoma — L. S. Carlson, M.D., R. Stuart,
M.D., J. D. Osguthorpe, M.D 409

EDITORIALS

Beliefs, Attitudes and Health Promotion — Charles S.

Bryan, M.D 84

Ciprofloxacin: Panacea or Blunder Drug? — Charles

S. Bryan, M.D 131

(The) Essential Healer — Charles G. Sasser, M.D. . . . 389
Into the Fray: The Community Hospital Treatment
of Acute Myocardial Infarction — E. Conyers

O’Bryan, Jr., M.D 533

Newborn Screening for HIV Antibody — Arthur F.
DiSalvo, M.D., William B. Gamble, M.D 208

FEATURES

Auxiliary Page 51, 91, 138, 212, 257, 301,

349, 395, 451, 497, 539, 589

Letter to the Editor 48, 347, 495

On the Cover 48, 89, 133, 21 1, 250, 297, 344,

393, 449, 496, 535, 587

President’s Page 3, 57, 95, 143, 253, 262, 307,

353,399,455,501,545

ASSOCIATION

CME Calendar 127, 203, 287, 437, 573

Gray Matter 49, 87, 135, 251, 299, 345, 387,

427, 489, 531, 585

Index to Volume 85 590

Information for Authors 52

In Memoriam 536

Physician Recognition Award ... 79, 249, 294, 443, 586

Physicians’ Advocacy and Assistance Committee . . . 537

SCMA Newsletter 29, 71, 109, 175, 229, 279, 323,

371, 421, 473, 517, 565

ONE HUNDRED FORTY-FIRST
ANNUAL MEETING

Introduction

Schedule of Events

Delegates and Alternates

Officer Reports

Trustee Reports

Committee Reports

Report of the Executive Vice President

SCMA Delegation to the AMA Report

Report of the Editor

SCMA Members’ Insurance Trust Report

SCIMER Report

SOCPAC Report

Report of the S. C. Medical Care Foundation .
Report of the S. C. Department of Health and

Environmental Control

Report of the S. C. State Board of Medical

Examiners

Resolutions

AMA Special Guest

SOCPAC Luncheon Speaker

Leonard W. Douglas, M.D., Memorial Lecture

Speaker

Exhibitors

Acknowledgments

145

146
161
167
179
186
196

198

199

200
200
201

201

205

206
206
207

207

214

215

a 7 At

WERT
bookbinding

GfantviUc Pi

MAR-APR 1991^

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